'-;«:<:•>;■•:< 


C«i<',<''--'.-'.'.S''.".'. 


u 


A    HISTORY 


OF 


LARYNGOLOaY 


AND 


EHINOLOGT 


T 


BY 


JONATHAN  WRIGHT,  jVI.D. 

DIRECTOR    OF   THE    DEPARTMENT    OP    LABORATORIES,    NEW    YORK     POST-GRADUATE    MEDICAL    SCHOOL 

AND    HOSPITAL 


SECOND  EDITION,  REVISED  AND  ENLARGED 


LKA    &    FEBIGK  R 

PHILADELPHIA   AND   NEW   YOUK 

1914 


Entered  according  to  the  Act  of  Congress,  in  tlic  j'car  1914,  by 

LEA    &    FEBIGER 
in  the  Odice  of  the  Librarian  of  Congress.     All  rights  reserved. 


THIS    BOOK    IS 
DEDICATED    TO   THE    MEMORY    OF 

]\IY  FATHER. 


PREFACE  TO  SECOND  EDITION. 


A  FEW  words  may  not  be  amiss  in  the  way  of  preface  to  this 
history  of  the  development  of  our  knowledge  of  the  nose  and 
throat. 

An  attempt  has  been  made  to  link  together  the  story  of  the 
records  of  the  nose  and  throat  in  medicine  with  the  general  drift  of 
medical  history,  with  the  salient  features  in  the  early  history  of 
the  civilization  of  mankind  and  with  the  general  literature  which 
has  a  bearing  upon  the  central  subject  of  the  work;  for,  as  Huxley 
has  said:  "Science  and  literature  are  not  two  things,  but  two  sides 
of  one  thing."  This  has  been  done  in  constant  fear  of  rendering 
the  story  too  verbose  and  pedantic,  but  with  the  earnest  hope 
of  riveting  the  attention  of  the  reader  in  a  way  which  can  not 
be  attained  in  the  routine  preparation  of  an  encyclopedia  or  a 
dictionary.  The  author  has  also  ventured  to  hope  that  the  informa- 
tion thus  laboriously  offered  will  not,  on  account  of  its  form,  prove 
less  accurate  or  extended  because  an  attempt  has  been  made  to 
make  it  more  attractive.  If  he  has  failed  in  realizing  these  ideals — 
and  who  ever  fully  succeeds? — he  may  comfort  himself  with  the 
reflection  that  the  labor  expended  in  an  attempt  to  attain  them 
has  been  fully  repaid  by  his  pleasure  in  the  work  itself. 

In  the  preparation  of  this  work  the  author  has  taken  his  notes 
chiefly  from  the  original  sources.  In  addition  he  has  made  use  of 
many  historical  works  both  of  medicine  and  of  general  literature. 
Among  the  former  those  of  Sprengel  (the  Frencli  edition  of  his 
history).  Baas  (in  English  translation),  Whittington,  and  especially 
Gordon  Holmes'  "History  of  the  Progress  of  Laryngology,"^  and 
Heyman's  "Geschichte  der  Laryngologie  und  Rhinologie"  in  his 
"Handbuch;"  among  the  latter  those  of  Buckle,  Ciuizot,  Freeman, 
Draper,  Lecky,  Gibbon,  Grote,  Ranke,  Prescott,  Kenan,  and 
many  others  have  been  systematically  read  during  the  course  of 
the  work. 

*  Med.  Press  and  Circular,  London,  188.5,  xci  (n.  s.  XL),  p.  49,  spq. 


vi  PREFACE   rO  SECOND  EDITION 

In  revising  his  book  for  a  second  edition  the  author  cannot  tail 
to  acknowledge  his  indebtedness  to  The  Laryngoscope  and  to  its 
editor,  Dr.  Max  A.  Goldstein,  for  publishing  the  text  of  the  first 
edition  in  their  columns.  Through  an  oversight  this  was  not 
explicitly  stated  when  it  was  first  published  in  book  form.  As  it 
was  not  a  part  of  the  author's  ambition  in  preparing  the  first  draft 
of  the  work  that  it  should  eventually  appear  in  })ermanent  form, 
and  inasmuch  as  the  text  was  furnished  from  the  columns  of  that 
journal  without  emendation,  naturally  that  care  was  not  given  to 
various  matters  in  its  preparation  which  is  essential  to  its  existence 
as  a  book. 

There  is  in  press  at  this  time  a  valuable  and  exhaustive  history 
of  laryngology  in  Germany.  Its  author,  Dr.  Karl  Ivassel,  of  Posen, 
has  with  the  greatest  courtesy  furnished  advance  proof-sheets, 
which  show  that  it  enters  more  into  detail  than  this  work,  but 
differs  somewhat  from  it  as  to  references  to  contemporaneous 
events  in  the  general  history  of  civilization. 

The  author  desires  to  acknowledge  his  indebtedness  to  Semon's 
Centralblatt  fur  Laryngologie  und  Rhinologie.  Without  it  the  task 
of  collecting  such  data  as  have  been  added  would  have  been  too 
great.  He  desires  also  to  acknowledge  a  personal  debt  of  long 
standing  to  Sir  Felix  Semon,  who  urged  him  years  ago  to  under- 
take the  present  task  and  whose  appreciative  words  in  regard  to 
the  first  edition  are  still  gratefully  remembered. 

The  author  desires  to  express  his  appreciation  of  the  work  of 
Mr.  Frank  Place,  of  the  librarv  staff  of  the  New  York  Academ\'  of 
Medicine,  who  has  undertaken  to  confirm  and  revise  the  references. 

J.  W. 

New  York  City,  1914. 


CONTENTS. 


Introduction         17 

Physiognomy  of  the  No«e. 

Etymology  of  the  Nose. 
Egyptian  Medicine 21 

Specialists  in  Egypt. 

Herodotus'  Account  of  Them. 

The  Breath  of  Life. 

The  Papyros  Ebers. 

The  Exodus  of  the  Jews. 

Penalties  for  Malpractice. 
Chaldean  Medicine 24 

The  Records  of  Magic. 

Their  Introduction  in  Rome. 

The  Medicine  of  the  Market  Place. 

Stercoraceous  Drugs. 

^Yitch  Medicine. 

Pliny  and  the  Therapy  of  the  Magi. 

Its  Contact  with  Greek  Medicine. 

The  Zend  Avesta  and  the  Medicine  of  the  Parsees. 
The  Medicine  of  the  Talmud 27 

Diphtheria  Among  the  Babylonian  Jews. 

The  Relation  to  the  Zend  Avesta. 

Tracheotomy. 

Nasal  Polyp  and  Ozjena. 
Hindu  Medicine 28 

Its  Puzzling  Chronology. 

Its  Relation  to  Greek  Medicine. 

Susruta  and  Hippocrates. 

Reference  in  the  Rig  Veda  to  Tracheotomy. 

Charaka  Samhita. 

The  Trace  of  Humoral  Pathology. 

Uvulotomy  and  Tonsillotomy. 

Rhinoplasty. 

Vaporizations  and  Fumigations  and  the  Intranasal  Use  of  Oil. 

Sternutatories. 

Foreign  Bodies  in  the  Throat. 

Fracture  of  the  Nose. 

The  Physiognomy  of  Death. 
Pre-Hippocratic  Medicine  in  Greece 35 

Its  Oriental  Derivation. 

Its  Occidental  Transformation. 

Civilization  in  Greece. 

Ancestry  of  Hippocrates. 

Greek  Medicine  at  the  Siege  of  Troy. 

The  Nose  and  Throat  in  Homer. 

Etymology  of  Greek  Words  for  Throat. 

Pharynx,  Larynx. 

Drink  in  the  Larynx. 

Early  Greek  Superstition. 

The  Early  Philosophers  and  Their  Ideas  of  Anatomy  of  the  Xo.se  and 
Throat  and  tlie  Eustachian  Tube. 

Goats  Breathing  through  their  Ears. 

The  Atomic  Theory  and  its  Relation  to  Voice  Production  and  Hearing. 


viii  CONTENTS 

The  HippocRATir  Treatises 43 

Hippocrates  as  a  Specialist  Among  Philosophers. 

Oriental  and  Occidental  Mentality. 

The  Era  of  Hipijocrates. 

The  Jilsclepiadae. 

The  Destination  of  Fluids. 

The  Origin  of  Catarrhs. 

"Cor.\za"  in  a  Double  Meaning. 

Coryza  in  Old  People. 

Acute  Throat  Inflammation. 

Diphtheria. 

Intubation. 

Cynanche  and  Parac^'iianchc. 

Uvulotomy  and  Evulsion  of  the  Tonsils. 

Fractures  of  the  Nose. 

Shceps'  Lung  as  an  Intranasal  Splint. 

Bandages  on  the  Nose. 

Syphilis. 

Nasal  Polypi  and  the  Methods  of  Their  Removal. 

Ejjistaxis. 

Vicarious  Menstruation. 

Sinusitis. 
From  Hippocrates  to  Celsus 59 

Tlie  Schools  and  Libraries  of  Pergamos  and  Alexandria. 

Anatomy  of  Aristotle,  Praxagoras,  Herophilus,  Eudemis. 
Roman  Medicine 64 

Cato,  the  Censor,  and  Nasal  Polypus. 

The  Introduction  of  Greek  Learning  into  Rome. 

Anatomy  and  Physiology  in  the  Time  of  Cicero. 

Asclepiades. 

His  Opinion  of  Synanche  and  of  Laryngotomy. 
Celsus  and  the  Pre-galenic  Writers 66 

Celsus    on    Coryza,   Angina,    Diphtheria,   Oza;na,   Nasal     Polypi,    the 
Tonsils,  and  the  Uvula. 

The  Therapy  of  Plin\-. 

Aretaeus  on  the  Uvula,  Syphilis. 

Cynanche,  Laryngotomy,  Syriac  Ulcer  or  Diijhtheria,  and  the  Manner 
of  Death  from  It. 

Rufus  of  Ephesus  and  the  Tonsils. 

The  Tracheotomy'  of  Aiityllus. 

Coelius  Aurelianus  on  Synanche  and  its  Treatment. 

His  Reference  to  tlie  Intubation  of  Hippocrates. 
Galen 76 

His  Era. 

His  Anatomy. 

The  Intermaxillary  Bone. 

The  Internal  Nose  and  its  Functions. 

The  Voice. 

The  Larj'nx  as  the  Instrument  of  the  Voice:  Its  Structure. 

The  Origin  of  the  Voice. 

Drink  to  the  Larynx. 

Hoarseness. 

The  Glands. 

The  Recurrent  Nerves. 

Hmnoral  Pathology. 

Anosmia. 

P(jlypi,  Ozu'iia  and  its  Therapy. 

\'arieties  of  Cynanche. 

Diphtheria. 

"latros." 

The  Tonsils,  the  Uvula,  and  Their  Amputation. 
The  Greek  Writers  ok  the  Eastern  Empire 87 

Incantations,  .Vmulets,  and  Charms. 

Constantinople  and  its  Warring  Sects. 

Cassius  Felix  and  Dijjhtheria. 


CONTENTS  IX 

The  Greek  Writers  of  the  Eastern  Empire: 

Nemesius  and  the  Circulation  of  the  Blood. 

Marcellus  Empiricus. 

The  Swallow  Prescription. 

Amputation  of  the  Tongue. 

Aetius,  His  Invocation  to  Jesus  Christ. 

Alexander  Trallianus. 

Theophilus  on  the  Olfactory  Nerves  and  the  Cribriform  Plate  of  the 
Ethmoid. 

Paulus  Aegineta  on  the  Operations  of  Tonsillotomy  and  Laryngotomy 
and  His  Use  of  the  Knotted  String  for  Nasal  Polypi. 
The  Arabians 96 

The  Transfer  of  Civilization  to  Them  and  Their  Cultivation  of  It. 

Their  Conquests. 

Destructions  of  the  Alexandrian  Libraries. 

The  Arabian  Renaissance  of  Learning. 

The  Inferior  Maxilla. 

Tracheotomy. 

The  Cautery. 

Tonsillotomy. 

Nasal  Speculimi. 

Stercoraceous  Therapy. 

A  Postnasal  Tumor. 

A  Relaxed  Palate. 

Haly  Abbas. 

Albucasis. 

Avenzoar. 

Mesua. 

Averrhoes. 
The  Pre-Renaissance  Period 104 

Learning  in  the  Middle  Ages. 

Gregory  the  Great. 

The  Schools. 

Ignorance  and  its  Beginning  Modifications  by  the  Influence  of  Arabian 
Science,  of  the  Church,  of  the  Crusades,  of  the  Fall  of  Constantinople. 

Italian  Science. 

The  School  of  Salerno. 

Hoarseness. 

"Squinantia." 

Operation  for  Nasal  Polypi. 

Tonsillotomy. 

Uvulotomy. 

Tracheotomy. 

Constantine,  the  African. 

Arnold  di  Villanova. 

Henry  of  Amondeville. 

Gui  di  Cauliac. 

Their  Dependence  on  Arabian  Science. 
The  Renaissance 115 

The  Influence  of  Maritime  Commerce. 

Petrarch. 

The  Gothic  Cathedrals. 

The  Hospitals  of  Saint  Louis. 

The  School  of  Bologna. 

Revival  of  the  Study  of  Anatomy. 

Mondino  di  Luzzi. 

Subservience  to  Galen. 

Berengar  del  Carpi. 

The  Cartilages  of  the  Larynx. 

The  Sphenoidal  Sinus. 

Vesalius  and  the  Revolt  from  the  Authority  of  Galen. 

His  Anatomical  Plates. 

Human  Dissection. 

The  Olfactory  Nerves. 

The  Iiiterniaxillar\-  Bone. 


X  CONTENTS 

The  Renaissance: 

"Glands"  of  the  Throat. 

The  Puhnonary  Circulation. 

The  Turhiiuitcd  Bones. 

Anatomy  of  the  Larj-nx. 

The  Works  of  Fabricius  ab  Acquapendente  and  Casscrius  on  the  Struc- 
ture and  Function  of  the  Larynx. 
The  Reformation  anu  the  Diffusiom  of  Knowledge 126 

The  InciuisitioM  and  tlio  Index  Expurgatorius. 

The  Aid  of  the  Church  in  the  Acciuisition  of  Knowledge  and  its  Later 
Restraint  of  its  Spread. 

Decline  of  Commerce,  Arts,  and  Sciences  in  Italy. 

The  Diffusion  of  Knowledge  through  Wars  and  the  Founding  of  Uni- 
versities and  Learned  Societies. 

The  Beginnings  of  Physiology. 

The  Circulation  of  the  Blood. 

The  Olfactory  Nerves  and  the  Theory  of  Willis. 

The  Vascular  Theory  of  the  Nasal  Glands  and  Other  pre-Schneiderian 
Theories. 

The  "de  Catarrhis"  of  Schneider. 

The  Correction  of  Errors  as  to  Catarrhs  and  the  Evolution  of  the 
Knowledge  of  Mucous  Glands. 

The  Chyliferous  and  Lymphatic  Systems. 

The  Microscope. 

The  Pharyngeal  Tonsil. 

The  latrophysical  and  latrochemical  and  other  Seventeenth  Century 
Theories. 

The  Disappearance  of  Chaldean  Therapy. 
The  Results  of  the  Renaissance 141 

Sixteenth  Century  Views  as  to  Diseases  of  the  Nose  and  Throat. 

The  Treatment  of  Oza^na  and  Tonsillar  Hypertroi)hy. 

Instruments  for  Operations  on  the  Uvula. 

Tobacco  and  Tea  Therapy. 

Syphilis. 

Prostheses. 

Rhinoplasty  of  Tagliacozzi. 

Epidemics    of    Influenza,    Pertussis,    Diphtheria,    Scarlet    Fever,    and 
their  Differentiation. 

The  Tracheotomy  of  Fabricius  and  the  Tubes  of  Guido-Guidi. 

Laryngocentesis  and  its  Application  in  Cases  of  Drowning. 

The  Modern  0])eration  of  Tracheotomy  and  Laryngotomy. 

Their  Em()loyni('nt  in  Diphtheria. 
Intranasal     Sukgery     and     Pathology     of     the     Seventeenth     and 

Eighteenth     Centuries 161 

Operations  for  Nasal  Polypi. 

The  Forceps  of  Aranzi  and  Fabricius  ab  Acquapendente  and  the  Harpsi- 
chord Wire  Snare  of  Fallopius. 

The  Instruments  of  Levret  and  of  Benjamin  Bell  and  Belloc's  Sound. 

The  Pathogenesis  of  Nasal  Polypi. 

The  Anatomy  of  the  Accessory  Nasal  Sinuses  and  Speculations  as  to 
their  P^unctions. 

Wounds  of  the  Frontal  Sinus. 

Worms  in  the  Sinuses. 

Description  of  the  Maxillary  Sinus  by  Highmore  ami  the  Operation  ot 
Cowper,  his  Predecessors  and  Followers  on  It. 

Normal  and  Pathological  Anatomy  of  the  Nose  and  Throat. 

Deviations  and  Sjjurs  of  the  Nasal  Septum. 

The  Ccrebrosiiinal  Fluid. 

Diphtheria. 
The  Prelaryngoscopic  Era 178 

The  Intermaxillary  Bone. 

Bichat  and  the  DifTerentiation  of  the  Tissues. 

Special  Treatises. 

Olfaction. 

Jacobson's  Organ. 


CONTENTS  XI 

The  Prelaryngoscopic  Era: 

The  First  Separate  Treatises  on  the  Diseases  of  the  Nasal  Fossae  and 
their  Sinuses. 

The  Sj'stems  of  Medicine. 

Bretonneau  and  Diphtheria. 

The  Epiglottis. 

Innervation  of  the  Larynx. 

Modern  Theories  of  Voice  Production. 

Photography  of  the  Larynx. 
Laryngeal  Phthisis 193 

Morgagni,  Lieutaud,  Petit,  Portal,  Sauve,  Saignelet. 

Tubercle  as  Named  by  Baillie. 

Laryngeal  Tubercle  as  seen  by  Broussais. 

Lack  of  Differentiation. 

Catarrhal,  Syphilitic,  Cancerous,  and  Tubercular  Laryngeal  Phthisis. 

Catarrhal  L^lcers. 

Louis,  Trousseau,  and  Belloc. 

Rokitansky. 
Histology  and  Pathology  of  the  Mucous  Membranes 199 

The  Cell. 

The  Epithelium. 

The  Tonsils. 

Schleiden,  Schwann,  Yirchow,  Henle,  Bowman,  KoUiker,  Sappey,  His, 
Waldeyer. 
Prelaryngoscopic  Ther.'VPy 201 

Tonsillotomes. 

Galvanocautery  Snare. 

Horace  Green  and  His  Intralaryngeal  Applications. 

The  Attempts  of  Bretonneau,  Trousseau,  and  Belloc. 

The  Intubation  of  Desault,  Loiseau,  and  Bouchut. 
The  Lary'ngoscope 203 

Bozzini,  Babington,  Cagniard  de  la  Tour,  Senn,  Liston,  Baumes, 
Selligue,  Warden,  Avery,  Manuel  Garcia. 

The  Difficulties  of  Techniciue. 

The  Introduction  of  it  in  Clinical  Work  by  Turck  and  Czermak. 

Their  Rivalry. 

Rhinopharyngoscopy. 

Artificial  Illumination  by  Czermak. 

The  Spread  of  the  Art  of  Laryngoscopy  to  other  Countries. 

The  Beginning  of  Special  Clinics,  Teaching,  Societies,  Journals,  Text- 
books of  Laryngology,  and  the  Enormous  Growth  of  its  Current 
Literature. 

The  Sequel  of  Laryngoscopy. 

Laryngeal  Tumors. 

Intralarj-ngeal  Operations  Before  and  After  the  Invention  of  Laryngo- 
scopy. 
The  Tonsils 217 

The  Pharyngeal  Bursa  and  Tonsil. 

Tornwaldt's  Disease. 

Embryology  and  Histology  of  the  Pharynx. 

Leukocyte  Emigration. 

Their  Origin  and  the  Controversy  in  Regard  to  It. 

Their  Relation  to  the  Epithelium. 

The  Accessory  Tonsil. 

The  Lymphoid  Cells. 

Wilhelm  Meyer  and  the  Discovery  of  "Adenoids." 

The  Physiology  of  the  Tonsils. 

Their  Absorptive  Power. 

The  Fat  Contents. 

Their  Relation  to  Dust. 

Internal  Secretion. 

Bacteriology  of  the  Tonsil. 

Diphtheria. 

Intul)ation. 

Follicular  Tonsillitis. 


xii  CONTENTS 

The  Tonsils: 

Vincent's  Angina. 

Tuberculosis  of  the  Tonsil. 

Their  Relation  to  Systemic  Infection. 

Tonsillar  Syphilis. 

Operations  on  Tonsils  and  Adenoids. 

Indications  for  it. 

Anesthesia  and  Position  in  It. 

Hemorrhage  and  Other  Sequoke  after  It. 

Ignipuncture  and  Galvanocautery  Snare. 

Bone  and  Cartilage  in  the  Tonsils. 

Nasal  Anatomy,  Physiology,  and  Pathology 238 

Nasal  Specula. 

Neglect  of  Nasal  Disease  after  the  Introduction  of  Laryngoscopy. 

Reflex  Neuroses. 

Gross  Anatomy. 

Relation  of  Nasal  to  Cranial  INIorphology. 

The  Erectile  Tissue. 

The  Glands. 

Intra-epithelial  Glands. 

Smooth  Muscle  Cells. 

Vascular  Mechanism  and  Sexual  Development. 

Elastic  Fibers. 

Olfactory  Epithelium. 

Nasal  Embryology. 

Nasal  Lymphatics. 

Pathogenesis  of  (Edematous  Nasal  Polypi,  Papillomata,  Adenomata, 

and  Papillarj-  Hypertrophies. 
Bleeding  Septal  Polypi. 
Kiesselbach's  Area. 
Cysts. 
Osteoma. 
Tuberculoma. 
Syphilis. 

Protozoal  CJranuloma. 
Malignant  Neoplasms. 
Nasal  Bougies. 
Cautery. 

Dental  Engine. 
Chronic  Intranasal  Diseask  and  its  Modern  Treatment      ....      259 

Reflex  Neuroses. 

Septal  Spurs  and  Deviations. 

Their  Etiology  and  Operations  for  Their  Relief. 

Submucous  Septal  Operation. 

Nasal  Snares. 

Cocaine. 

Adrenalin. 

Thrombokinase. 

Inhalations  and  Detergents. 

The  Compressed  Air  Spray. 

Improved  Illumination. 
The  Accessory  Nasal  Sinuses -69 

The  Beginnings  of  Interest  in  Disease  of  Them. 

Transillumination. 

Latent  Suppuration. 

Necrosing  ]']thni()iditis. 

Postmortem  Examinations. 

Bacteriology. 

Histology. 

Cysts. 

Teeth  in  the  Nose. 

Mucocele. 

Malignant  Tumors. 

Choanal  Polypi. 

Sinus  Tuberculosis. 


CONTENTS  xiil 

The  Accessory  Nasal  Sinuses: 

Rhinitis  Caseosa. 

Sinus  Ozsena. 

Embryogeny  and  Anatomy  of  the  Sinuses. 

Rontgenology,     Transillumination,     Irrigation,     the     Endoscope,     and 
Negative  Pressure  in  Diagnosis. 

Development  of  Operative  Technique  on  the  Different  Sinuses  and  the 
Hypophysis. 

Complications  of  Sinus  Disease. 

Sequelse  of  Operations  and  Trend  to  Conservatism. 

Local  Anesthesia. 

Vaccines. 
Bacteriology  of  the  Nose  and  Throat 296 

Mycosis  Pharyngis  or  Leptothrix  Buccalis. 

Actinomycosis. 

Nasal  Bacteria. 
Atrophic  Rhinitis 300 

Etiology. 

Histology. 

Treatment. 

Literature. 
Tuberculosis  of  the  Upper  Air  Passages 308 

Infection,  its  Portals  and  Paths. 

Primary  Laryngeal  Tuberculosis. 

Treatment  of  Laryngeal  Tuberculosis. 
Rhinoscleroma 317 

Recognition. 

Distribution. 

The  Bacillus  of  Frisch. 

Contagion. 

Treatment. 

AuToscoPY 319 

Lary'Ngeal  Paraly'sis 320 

First  Reports. 

Differentiation. 
"Cadaveric  Position"  of  the  Cords. 

Rosenbach-Semon  "Law"  or  the  Greater  Proclivity  of  Abductors  to 
Paralysis. 

The  Contracture  Theory. 

Central  Innervation  and  Cerebral  Localization. 

Toxic  Paralysis. 

Double  Posticus  Paralysis. 
Laryngeal  Cancer  and  its  Extirpation 327 

Laryngotomy. 

Thyrotomy. 

Laryngectomy. 

Intralaryngeal  Operation. 

The  Emperor  Frederick. 

Microscope  in  Diagnosis. 

Supposed  Transformations  of  Benign  into  Malignant  Growths. 

Semon's  Statistics. 

Prosthesis. 

Pachydermia  Laryngis. 
Epilogue 333 

Index  of  Personal   Names 335 

Index  of  Subjects 3-15 


INTRODUCTION. 


In  every  age  there  have  been  attempts  to  draw  from  the  appear- 
ance of  the  countenance,  especially  from  the  shape  and  size  of  the 
nose,  prognostications  as  to  the  mental  and  physical  attributes  of 
men;  but  although  many  are  the  rules  laid  down  for  the  guidance 
of  observers,  they  are  of  little  value;  for  while  doubtless  the  features 
tell  their  story  to  us  occasionally,  if  we  are  close  observers,  in 
spite  even  of  the  modern  and  scientific  treatises  of  Bell  and  of 
Darwin,  the  expressions  are  too  fugacious  and  elusive  to  allow  us 
to  gather  from  them  any  reliable  data  as  to  the  characteristics  of 
the  individual.  The  extensive  disquisitions  on  character  drawn 
from  the  aspect  of  the  features  are  largely  flights  of  a  foolish  and 
puerile  fancy. 

Physiognomy  of  the  Nose. — Xo  longer  ago  than  1820  we  find  it 
stated  in  a  scientific  work^  that  "a  long  and  pointed  nose  passes 
for  a  sign  of  sagacity.  A  short  and  blunt  nose  marks  a  simplicity 
of  mind,  easy  to  deceive  and  with  very  little  foresight.  A  little 
nose,  thin  and  movable,  denotes  a  natural  mocker.  Large  noses 
are  an  indication  of  heaviness,  for  they  bespeak  the  lymphatic 
nature  of  the  complexion.  Twisted  noses,  they  say,  are  a  sign  of 
an  obliquit}'  of  mind;  but  an  aquiline  nose,  large  and  muscular, 
announces  force  and  courage;  a  flattened  nose  an  inclination  to 
luxury;  in  fact,  it  is  thought  there  is  a  correspondence  between 
the  sexual  organs  and  that  part  of  the  countenance." 

"Noscitur  ex  labiis  quantum  sit  virginis  antrum 
Noscitur  ex  naso  quanta  sit  hasta  viri." 

This  is  a  quotation  drawn  from  a  literature  stimulated  by  the 
recent  excursions  of  Lavater  into  the  realms  of  uncontrolled  and 
uncritical  observation. 

On  the  testimony  of  Plutarch  we  learn  that  the  Persians  most 
admired  the  hawk-nosed  type  of  man  as  resembling  Cyrus,  their 
best  beloved  king.  This  saying  we  find  echoed  in  the  sixteenth 
century  by  Riolan-  and  Laurentius,^  the  latter  declaring,  with  how 

1  Diet,  des  Sciences  Medicales,  Paris,  1820,  Vol.  XXXXII,  p.  220. 
-  Opera  Omnia,  Paris,  IGIO,  Anatome,  Cap.,  LIII,  De  Naso. 
^  L'Historie  Anatomique  traduit  par  Size,  Paris,  1610,  p.  1374. 

2 


18  INTRODUCTION 

much  truth  I  do  not  know,  that  the  Egyptians  in  tlieir  liieroulyphs 
use  the  figure  of  a  nose  to  designate  a  man.  We  may  plainl\'  see 
the  tyi)e  of  Cyrus  in  Bellini's  jiortrait  of  the  Sultan  ]\Iohammed.* 
We  learn  from  the  Old  Testament  (Levit.  XXI,  IS)  that  there  was 
a  prejudice  among  the  Patriarchs  against  flat-nosed  people. 

But  in  spite  of  these  predilections  of  the  Caucasian  race  we  find 
among  the  native  negroes  and  the  Chinese  dift'erent  ideals  as  to  the 
beautv  of  the  nose.  "The  ancient  Huns  during;  the  age  of  Attila 
were  accustomed  to  flatten  the  noses  of  their  infants  with  bandages 
for  the  sake  of  exaggerating  a  natural  conformation.  With  the 
Tahitians  to  be  called  long-nosed  is  an  insult  and  they  compress 
the  noses  and  foreheads  of  their  children  for  the  sake  of  beauty. 
So  it  is  with  the  ^Malays  of  Sumatra,  the  Hottentots,  certain 
negroes,  and  the  natives  of  Brazil."- 

In  attempting  to  present  an  outline  of  the  growth  of  our  knowl- 
edge of  the  nose  and  throat  and  of  their  diseases,  it  must  be  remem- 
bered that  a  complete  and  intelligent  review  of  the  subject  can- 
not be  obtained  by  beginning  our  study  with  the  discovery  or 
rather  with  tlie  introduction  of  the  use  of  the  laryngoscope.  That 
would  be  a  consideration  of  the  history  of  laryngoscopy  and  its 
sequelse  in  the  history  of  the  diseases  of  the  upper  air  tract,  and 
of  the  growth  and  development  of  technical  skill.  However  great 
may  have  been  the  revolution  wrought  by  Tiirck  and  Czermak  in 
tliis  field,  the  history  of  rhinology  and  laryngology  begins  not  with 
the  invention  of  the  speculum  and  the  laryngeal  mirror,  but  with 
the  earliest  records  of  the  civilization  of  man.  In  fact,  it  is  reason- 
able to  conjecture  that  it  is  only  the  lack  of  records  which  prcAcnts 
us  from  tracing  knowledge  of  the  diseases  of  the  nose  and  throat 
still  farther  back  into  prehistoric  times.  It  must  necessarily  be 
that  any  disease  of  the  respiratory  system  causing  obstructive 
dyspnoea,  or  any  affections  causing  deformity  and  discharge  from 
the  nose,  would  have  attracted  the  attention  of  the  medicine  men 
of  our  primeval  ancestors.  Injuries  to  the  head  must,  as  freciuently 
then  as  now,  have  involved  the  nasal  organ.  Indeed,  we  shall 
find  in  the  very  earliest  Hindu  and  Greek  records  evidences  of  the 
care  and  attention  devoted  to  the  study  of  this  branch  of  the 
medical  art.  We  shall  also  find  that  to  some  extent  the  nose  and 
nasal  disease  in  the  earliest  times  possessed  proportionately  a 
larger  interest  for  medical  men  than  it  did  in  more  recent  and 
more  enlightened  times,  until  the  beginning  of  the  growth  of  what 
we  are  pleased  to  call  ^lodern  lihinology.  Exposed  to  accidental 
and  intentional  injury  in  the  sports  and  wars  of  the  ancients, 
mutilated  bj^  the  deliberate  acts  of  a  cruel  justice  before  the  days 
of  jails,  or  in  the  fierce  outbursts  of  passion  and  revenge,  traumatic 

'  Thi.s  rimy  be  conveniontly  rofcrrcd  to  in  Mrs.  Oliphant's  Makers  of  Venice. 
-  Darwin's  Descent  of  Man,  Part  III,  Chap.  XIX. 


ETYMOLOGY  OF  NOSE 


19 


conditions  of  the  nose  have  occupied  necessarily  not  only  a  very 
large  place  in  the  medical  literature,  but  in  the  secular  writings  of 
former  civilizations: 

"Atque  hie  Priamiden  laniatum  corpore  toto 
Deiphobum  vidit,  lacerum  crudeliter  ora, 
Ora  manusque  ambas,  populataqiie  tempora  raptis 
Auribus  et  truncas  inhonesto  volnere  naris." 

— Virgil,  Aeneis  VI,  494. 

Innumerable  colloquial  phrases  in  all  known  tongues  still  testify 
to  its  importance  as  a  symbolical  figure  of  speech. 

Etymology  of  Nose. — It  would  seem  that  the  remarkable  coinci- 
dence, pointed  out  by  Hvorka,^  that  the  word  "nose"  has  the  same 
stem  in  all  known  European  languages,  might  be  explained,  as  he 
suggests,  on  phonetic  principles,  and  it  is  very  likely  that  the 
nasal  resonance  of  the  "  n"  followed  by  a  vowel  has  had  an  influence 
in  preserving  the  stem  from  radical  changes;  but  it  is  difficult  to 
see  why,  on  this  ground,  the  sibilant  "s"  should  enter  almost 
universally  into  the  word.  The  following  is  the  list  of  languages 
quoted  by  Hvorka  in  a  little  different  sequence,  with  the  accom- 
panying word  for  nose: 


Sanskrit . 
Old  Indian 
Old  Persian 
Zendic    . 
Hebraic 

Greek 

Latin 
Italian    . 
Spanish 
French    . 
Gothic    . 
Old  Norse 
Old  German 
Middle  German 
Anglo-Saxon 
English  . 


Nas  Danish Noesen 

Nasa  Netherland       ....  Neeus 

Nana  Modern  German   .  .  Nase 

Naonha  Old  Slavonic    ....  Nosz 

Nohar  Old  Bulgaric    ....  Nosii 

/p'-r  Old  Prussian    ....  Nozy 

\p/vo-  Lithuanian       ....  Nosis 

Nasus  Lettic Nasis 

Naso  Bohemian Nos 

Nariz  Polish Nos 

Nez  Polabian Nus 

Nasa  Upper  and  Lower  Sorbian  Nos 

Nos  Russian Nos 

Nasa  Servian Nos 

Nase  Croatian Nos 

Nose  Slovenic Nos 

Nose  Swedish Niisan 


It  thus  seems  evident  that  there  has  been  a  direct  transmission 
from  the  ancient  Sanskrit  of  the  word  nose  to  the  modern  languages 
of  Europe,  one  of  the  innumerable  etymological  evidences  of  the 
origin  of  our  branch  of  the  human  race.  If  we  look  at  a  photograph 
of  a  miscellaneous  group  of  natives  of  Calcutta  or  Bombay,  and 
then  glance  out  of  the  window  at  the  pedestrians  along  Broadway 
or  the  Strand,  we  will  note  that  not  only  the  word  has  been  trans- 
mitted, but  the  characteristics  of  the  feature  for  which  it  stands. 

It  may  not  be  without  interest  in  this  connection  to  supplement 


1  Hvorka:  Die  Aeussere  Nase,  1893. 


20  INTRODUCTION 

Hvorka's  investigations  by  examining  other  languages  ha\  iug  no 
known  affiliation  with  the  so-called  Arvan  stock: 

Chinese Pe 

Japanese Hana 

Congolese  (Africa) Djolo 

Mexican  (Nahaute) Yacatl 

South  American  Indians. 

Aymara Nasa 

Moxas Nusiri 

Incas  (Quichua) Seneca 

North  American  Indians. 

Cree Miskiwan 

Lenape  (Delaware) Wikiwan 

Onondaga Onionchia 

Chinook Bekats 

Clallam  (Washington  Territory) Nuk'su 

A  number  of  vocabularies  of  other  North  American  languages 
show  no  such  conformity  as  the  European  languages.  There  is, 
however,  as  will  be  seen,  a  suggestion  of  a  common  derivation  of 
the  word  even  as  between  the  tongues  of  the  three  continents 
(Europe,  Asia,  America),  but  it  would  lead  us  too  far  astray  to 
pursue  the  question  further.  It  will  be  noted  that  the  persistence 
of  the  nasal  "n"  and  the  sibilant  "s"  is  not  so  marked  in  the 
languages  of  the  non-Aryan  races  of  the  world. 


THE  NOSE  AND  THROAT  IN  MEDICAL  HISTORY. 


EGYPTIAN  MEDICINE. 

N  a  volume  published  from  the  unfinished  manu- 
script of  A.  ]\Iariette  Bey,  entitled  "Les  Mas- 
tabas  de  I'Ancienne  Empire,"^  among  many 
others  is  a  fac-simile  of  a  drawing  on  a  slab 
found  in  the  tombs  of  one  of  the  old  Egyptian 
kings.  The  grave  in  which  the  slab  was  found 
is  said  to  date  back  to  the  fifth  dynasty,  a 
matter  of  .3500  years  before  the  birth  of 
Christ.  On  the  slab  is  the  delineation  of  a 
physician  and  his  wife  with  her  hand  resting  aftectionately  on 
his  shoulder.  He  was  the  medical  attendant  of  King  Sahura 
and  his  name  was  Sekhet'enanch,  but  what  the  name  of  his  wife 
was  does  not  appear.  It  is  said  to  have  been  everywhere  erased 
from  the  tablets.  What  subsequent  domestic  infelicity  this  may 
hint  at  does  not  appear.  Edward  ^leyer,  in  his  "  Geschichte  des 
Alten  .Egyptens"  (II,  p.  95),  translates  some  of  the  inscription 
relating  to  the  physician  in  such  a  manner  that  it  appears  the  king 
had  ordered  it  to  be  engraved  as  a  testimony  of  gratitude  to  his 
doctor  because  he  had  "made  his  nostrils  well."  He  wishes  him, 
therefore,  long  life  and  happiness.  This  tablet  had  formerly  been 
set  up  in  the  king's  palace  in  an  ante-room  where  all  might  see  and 
read.  ^Ye  see  hereby  not  only  the  antiquity  of  medicine,  but  also 
the  antiquity  of  certain  propensities  which  have  not  yet  disappeared, 
so  the  uncharitable  say,  from  the  activities  of  its  devotees;  for  we 
read  further  in  Meyer's  text  that  this  method  of  recompense  was 
suggested  to  the  king  by  Sekhet'enanch  himself.  Truly  "Vita 
brevis,  ars  longa."  However,  it  does  not  appear  that  this  early 
practitioner  of  medicine  and  violator  of  medical  ethics  was  neces- 
sarily a  rhinologist,  for  the  word  "nose"  in  this  place,  according 
to  the  translator,  seems  to  have  signified  "breath  of  life."  This, 
of  course,  makes  the  meaning  of  the  passage  very  indefinite.  It 
is  an  indication,  howe\-er,  that  five  thousand  years  ago  they  recog- 
nized the  nose  as  belonging  to  the  respiratory  system,  a  fact  to 
which  it  has  frequently  been  necessary  to  draw  attention  in  later, 
and  we  are  fain  to  believe,  more  enlightened  times.    Voltolini-  has 


1  On  Plate  D  12. 


-  Die  Krankheiten  der  Nase,  Breslau,  1888,  p.  16. 


22  EGYPTIAN  MEDICINE 

quoted  ]\Ioses  for  authority  (Genesis  II,  7),  that  the  nose  was 
recognized  as  an  orjian  of  the  respiratory  apparatus  when  the  "Lord 
God  formed  man  of  the  chist  of  the  ground  and  l)reathed  into  his 
nostrils  the  breath  of  life."  According  to  Kautzsch  this  utterance 
was  recorded  only  about  400  years  before  Christ  or  about  the  end 
of  the  life  of  Hippocrates  as  it  is  usually  reckoned  (Kassel). 

This  reference  and  several  others  in  the  Sacred  Writings  point 
directly  to  the  nostrils  as  emblematical  of  life  and  of  the  soul.  It 
is  not  at  all  improbable  that  this  figure  of  speech  had  its  origin  in 
Eg}'pt  where  the  nostrils  were  the  route  by  which  the  contents  of 
the  cerebral  cavity  were  extracted  in  the  more  expensive  methods 
of  the  uni^'ersal  practice  of  embalming  the  dead.  The  exodus  of 
the  people  of  Israel  from  Egypt  is  said  to  have  taken  place  at  a 
date  subsequent  to  that  ascribed  to  the  compilation  of  the  "  Papyros 
Ebers"  (1550  B.C.). 

Specialists  in  Egypt. — As  to  the  possibility  of  Sekhet'enanch 
having  really  been  a  rhinologist,  we  are  supported  only  by  a  single 
historical  reference.  Herodotus  (II,  84)  makes  a  very  positive 
statement  as  to  specialization  in  Egyptian  medicine,  but  makes 
no  reference  to  rhinology,  unless  we  suppose  reference  to  the  head 
to  include  affections  of  the  nose  and  throat.  The  passage  reads 
in  Iiawlinson's  translation  (vol.  ii,  p.  136)  thus:  "Medicine  is 
practised  among  them  on  a  plan  of  separation;  each  physician 
treats  a  single  disease  and  no  more;  thus  the  country  swarms  with 
medical  practitioners,  some  undertaking  to  cure  diseases  of  the 
eye,  others  of  the  head,  others  again  of  the  teeth,  others  of  the 
intestines,  and  some  those  which  are  not  local."  'v^  ok  cr^Tfnxrj  xaza 
rath  Oifc  nko(i.(Jzar  iiap  vo'joo')  ixaazo^  ir^T[>6^  iazc  '/.at  oh  iz/MrJoy^. 
/Tdcvra  o  tr^zoCo'j  lazt  -rJ.ia:  ol  itkv  yao  ocpdoliuTw  Ir^znoi  y.azzazu.ot,  ol 
ok  /.z(fa/:/j:;,  ol  ok  doot^Ziov,  ol  oi  zuju  xaza  uv^d'Ji^,  o:  ok  zcov  d<faueco> 
vo'jacov.^^ 

Maspero^  and  P>man-  are  both  inclined  to  believe  that  Herodotus 
somewhat  exaggerated  the  extent  to  which  the  specialization  of 
medicine  was  carried  in  ancient  Egypt,  but  Montaigne,  that 
garrulous  and  delightful  old  Erench  classic,  not  only  credited 
the  statement  of  Herodotus  but  approved  of  it,  for  he  says:^  "The 
Egyptians  were  right  in  neglecting  the  general  calling  of  physician 
and  of  dividing  the  profession;  for  each  illness,  for  each  part  of 
the  body,  there  was  an  attendant,  and  therefore  each  part  was 
more  skilfully  and  less  blindly  treated,  because  they  studied  each 
one  specially." 

It  has  been  conjectured  tliat  this  specialization  of  medicine  in 
Egypt,  when  at  the  height  of  her  civilization,  was  due  to  the  same 
causes  which  have  produced  it  today.     The  teeming  population 

1  Maspero:     Dawn  of  Civilization. 

^  Ernian:     Life  in  Ancient  Epiypt. 

^  Montaigne:     Essais,  Livre  II,  Cap.  XXXVII. 


THE  PAPYROS  EBERS  23 

in  the  fertile,  irrigated  valley  of  the  Nile  dwelt  largely  in  cities'- 
and  these  enormous  aggregations  of  population,  which  is  the 
striking  phenomenon  of  modern  civilization,  furnish  the  only  con- 
ditions under  which  such  subdivisions  of  the  arts  and  sciences  are 
possible.  The  whole  matter,  however,  resting  as  it  does  upon  this 
passage  in  Herodotus,  is  involved  in  much  doubt  and  uncertainty .^ 
The  "Papyros  Ebers." — Whether  these  old  Egyptians  had  special- 
ists or  not,  it  is  evident  from  the  "Papyros  Ebers"  that  they  had 
physicians  who  observed  and  knew  how  to  treat  diseases  of  the 
nose  and  throat  after  a  fashion.  This  "Papyros"  is  the  earliest 
of  all  books  on  medicine  and  is  said  to  have  been  compiled  about 
1550  years  before  Christ,^  but  even  the  date  of  its  compilation  is 
somewhat  conjectural,  while  that  of  its  origin  is  wholly  so.  It  is 
supposed  by  some  to  be  merely  a  book  on  pharmacology,  but  as 
its  learned  translator^  has  stated,  it  is  more  than  that,  for  near 
the  end  it  deals  with  anatomy,  physiology,  pathology,  and  surgery. 
In  spite  of  the  practice  of  embalming,  anatomy  was  evidently 
largely  a  matter  of  fancy  with  these  early  doctors,  and  gave  no 
promise  of  the  great  development  which  the  Greeks  under  the 
Ptolemies,  in  the  future  city  of  Alexandria,  a  thousand  years 
later,  were  to  bring  about  in  it.  We  read,  page  181,  "There  are 
four  vessels  in  both  nostrils  of  which  two  carry  blood  and  two  carry 
mucus."  In  physiology  they  were  scarcely  less  at  sea,  for  when 
the  air  once  entered  the  nose  they  lost  track  of  it.  "  It  goes  to  the 
heart  and  the  rectum,"  says  the  author  of  the  "Papyros,"  a  few 
lines  farther  on.  It  is  evident  that  tumors  of  the  neck,  both  tuber- 
cular glands  and  goitre,  were  well  known  and  as  little  understood. 
It  must  be  remembered,  however,  that  the  translation  is  often 
uncertain  and  that  it  is  impossible  for  us  to  comprehend  exactly 
what  they  meant  even  when  the  equivalents  of  their  hieroglyphics 
are  selected  in  the  modern  languages.  "If  thou  findest  in  his 
throat  a  fatty  tumor  (?)  and  it  appears  like  an  abscess  of  the  flesh, 
which  can  be  reached  by  the  fingers,  thou  must  say  thereto,  'he 
has  a  fattv  tumor  in  his  throat;  I  will  treat  the  disease  with  a 

'  Egypt  in  the  time  of  Herodotus  contained  from  eighteen  to  twenty  thousand 
cities.  Under  the  successors  of  Alexander  it  is  said  to  have  contained  thirty 
thousand  towns.  (Baas.)  There  were  so  manj^  ph3'sicians  in  Egypt  that  Homer 
declared,  perhaps  as  an  early  instance  of  poetic  license,  they  were  all  physicians. 

-Cyrus  sent  for  an  eye  doctor  out  of  Egypt  (Herod.  IH,  1)  and  Darius 
(Ibid.  Ill,  129)  made  use  of  one  of  his  captives,  the  Greek  physician  Demo- 
cedes,  to  cure  him  of  a  sprain,  but  there  is  no  mention  of  a  nose  doctor  which 
I  can  find.  Democedes,  by  the  way,  was  the  first  physician  of  whose  life  and 
adventures  we  have  a  trustworthy  record,  and  his  romantic  and  interesting 
story  is  graphically  told  by  the  Father  of  History.  He  lived  490-430  years 
before  Christ,  and  was  paid  fabulous  prices  for  his  services  not  only  b}'  the 
Persian  King  but  by  his  countrymen. 

'  Moses  brought  Israel  out  of  Egypt  1300  years  before;  Christ,  and  hence, 
according  to  these  computations,  250  years  after  the  compilation  of  the  Papyi-os 
Ebers. 

^  Papyros  Ebers,  iibersetzt  von  Dr.  Med.  H.  Joachim,  Berlin,  1S90. 


24  CHALDEAN  MEDICINE 

knife,  taking  care  of  the  (blood)  vessels.' "  They  were  apparently 
very  chary  of  snrgical  procedures,  and  ('^•(•Il  in  this  place  it  is 
uncertain  from  the  translation  whether  the  author  does  not  really 
give  preference  to  ointments  and  cataplasms,  for  whicli  he  gives 
a  number  of  scarcely  recognizable  prescriptions. 

We  will  find  in  the  "Zend  Avesta"  that  the  surgeon  must  first 
thrice  essay  his  skill  upon  a  slave  or  a  lower  caste  man  before 
operating  on  their  betters.  Let  us  think  of  our  hospitals  and 
dispensaries  and  refrain  from  unkind  criticism.  If  they  neglected 
to  do  this  the}'  operated  at  the  peril  of  their  lives  on  the  high  caste 
man.  Such  a  penalty  was  calculated  to  encourage  conservatism 
if  it  obtained  in  old  Egypt  as  well  as  in  Chaldea. 


CHALDEAN  MEDICINE. 

Closely  allied  with  Egyptian  civilization  was  that  of  the  Chal- 
deans and  the  Assvrians,  but  scarcelv  anv  notice  has  come  down 
to  us  of  their  medical  attainments  beyond  the  records  of  magic. ^ 
the  incantations  and  the  invocations  of  good  and  evil  spirits,  which 
would  indicate  that  our  art  among  them  was  about  on  a  level  with 
that  of  the  American  Indians.  In  the  satires  of  Juvenal  we  find 
Chaldean  magic  much  cultivated  by  the  decadent  social  world  of 
Rome  against  which  he  aimed  his  shafts. 

"Chaldcis  sed  major  erit  fiducia;  quicquid 
Dixerat  astrologus,  credent  a  fonte  relatum 
Hammonis."     (VI.  552.) 

In  the  popularity  of  theosophy  and  the  mind  cure  and  the  faith 
cure  we  have  in  our  day  a  parallel  to  the  condition  at  Rome  so 
far  as  the  mystic  influences  of  the  Far  East  are  concerned. 

It  is  impossible  for  us  to  stretch  our  credulity  to  the  point  of 
believing  Herodotus  when  he  asserts  that  the  Babylonians  had 
no  physicians,  but  depended  on  the  wisdom  of  the  market-place, 
where  the  patients  were  exposed  for  the  benefit  of  the  comments 
of  pas.ser.sby.  Familiarity  with  human  nature  compels  us  to 
believe  that  even  if  they  possessed  no  medical  knowledge  they 
must  have  possessed  men  who  pretended  to  it,  and  others  who 
believed  in  their  assertions,  for  as  Celsus  remarked,  "JMedicina 
nu.squam  non  est." 

According  to  Sayce-  dog's  flesh  and  the  ordure  of  animals  were 
among  Chaldean  medicaments,  and  such  things  we  find  in  abun- 
dance in  the  "PapjTos  Ebers."    These  disgusting  drugs  we  will 

'Some  one  paraphrasing  Pliny  has  said:  "Magic  was  the  offspring  of 
medicine,  and  after  liaving  fortified  itself  with  the  shield  of  Astrology  it  borrowed 
all  its  splendor  and  authority  from  religion."  See  Pliny:  Hist.  Nat.  Lib., 
XXX.  Cap.  1-2. 

2  Hibbert  Lectures,  1887,  p.  84. 


THE  THERAPY  OF  THE  MAGI  25 

again  find  recommended  in  the  works  of  Galen,  ^Etius  and  Oribasiiis, 
among  those  prescribed  internally  and  even  for  internal  local  appli- 
cations in  throat  disease.  We  can  perhaps  therefore  understand 
Juvenal's  objections  to  the  Chaldeans,  and  we  may  see  from  his 
mention  how  these  articles  crept  into  the  later  medical  writings  of 
the  Roman  Empire  and  subsequently  appeared  among  the  drugs 
of  the  jNIiddle  Ages,  thus  transferred  from  the  plains  of  Mesopo- 
tamia to  the  banks'  of  the  Rhine  and  the  Thames.  The  belief 
in  the  efficacy  of  precious  stones  as  medicaments  is  first  found  in 
the  accounts  of  Babylonian  medicine  and  existed  far  into  the 
Renaissance  as  costly  articles  of  the  Pharmacopoeia. 

Witch  Medicine. — ^Mysterious  invocations,  gruesome  and  disgust- 
ing prescriptions  occupy  a  prominent  place  in  all  records  of  primitive 
medicine,  but  apparently  these  with  the  cabalistic  use  of  figures 
and  signs  have  long  lingered  in  the  records  of  medicine  and  in 
literature  as  the  heirlooms  of  Chaldean  sorcerv.  The  Faust  legend^ 
is  full  of  them.  The  Walpurgisnacht  in  Goethe's  "Faust"  has  a 
distinctly  Chaldean  flavor,  not  pleasant  but  weird.  We  recall 
the  dark  cave  in  "Macbeth,"  where  the  witches'  prescription  is 
compounded : 

"Fillet  of  a  fenny  snake 
In  the  cauldron  boil  and  bake; 
Eye  of  newt  and  toe  of  frog, 
Wool  of  bat  and  tongue  of  dog, 
Adder's  fork  and  blind  worm's  sting, 
Lizard's  leg  and  owlet's  wing." 

The  same  Chaldean  prescription  is  found  in  Horace,  where  the 
foul  witch  Canidea  orders: 

"Et  uncta  turpis  ova  ranae  sanguine 
Plumamque  nocturna;  strigis, 
Herbasque  quas  lolcos  atque  Hiberia 

Alittit  venenorum  ferax, 
Et  ossa  ab  ore  rapta  jejuna?  canis 
Flammis  aduri  Colchicis." 

— HoRATii  Fl.^cci  Epodon,  Liber  5,  V,  19  Seq. 

These  are  merely  Babylonian  or  Egyptian  prescriptions  in  meter. 

The  Therapy  of  the  Magi. — Pliny,-  who  believed  that  he  would 
be  able  to  include  all  the  wisdom  of  the  world  in  his  histories,  has 
left  behind  him  some  curious  information  as  to  therapeutics  derived 
from  Chaldean  or  Oriental  sources.  He  may  be  held  up  as  a  terrible 
example  to  the  gentlemen  who  still  believe  that  even  now  the 
whole  field  of  medical  science  does  not  oft'er  too  wide  a  scope  for 
their  mental  powers.  "I  find,"  says  he,  "that  a  cold  is  checked 
if  any  one  will  kiss  the  nostrils  of  a  mule."  "Inflammation  of  the 
fauces  and  the  pain  will  be  (aired  by  the  dung  of  kids  l^efore  they 
have  tasted  grass,  if  it  is  dried  in  the  shade."    "Gargling  with  the 

'  Faust  in  der  Geschichte  und  Tradition,  Kiesewetter,  Leipsic,  1893. 
2  Hist.  Nat.,  Lib.  XXX. 


26  THE  MEDICINE  OF   THE  PA  USEES 

milk  of  a  sheep  helps  the  tonsils  and  fauces."  "Anginas  are  helped 
by  a  goose's  gall  mixed  with  elaterium  and  honey — by  the  brain 
of  an  owl,  by  the  ashes  of  a  swallow  soaked  in  hot  water.  Ovid 
is  the  author  of  this  medicament."  These  suggestions  arc  taken 
at  random  and  do  not  exhaust  the  supply  of  therapeutical  measures 
for  nose  and  throat  diseases,  which  were  derived  from  the  IMagi 
by  Pliny,  to  whom  I  would  respectfully  refer  those  curious  in 
regard  to  or  desirous  of  profiting  by  such  garnered  wisdom.  Such 
things  still  are  to  be  found  in  the  folk-medicine  of  rural  communities 
to  a  surprising  extent.  These  relics  of  this  peculiar  phase  of  medical 
history  are  still  w  ith  us,  but  we  have  but  little  direct  knowledge 
of  Chaldean  medicine,  although  Sayce  has  lately  partly  deciphered 
"An  Ancient  Babylonian  Work  of  Medicine."^ 

For  some  mysterious  reason  Egyptian  civilization,  and  with  it 
Egyptian  medicine,  was  at  a  standstill  for  many  centuries  before 
the  downfall  of  the  Oriental  dynasties.  At  a  later  period  we  see 
the  same  phenomenon  among  the  Hindus.  Although  the  Greeks 
apparently  derived  at  least  the  foundation  of  their  learning  from 
these  sources,  they  were  far  in  ad\'ance  of  them  when  the  generals 
of  Alexander  (330  B.C.)  established  his  empire  over  Asia.  Even 
in  the  time  of  Xenophon  (401  B.C.),  two  generations  earlier,  the 
Persian  monarchs  were  surrounded  by  Greek  physicians  whom 
they  brought  to  their  courts,  usually  by  profuse  pecuniary  induce- 
ments, but  not  infrequently  by  force  and  by  kidnapping.  It  was 
Ctesias,  a  Greek  physician  and  historian,  who  treated  the  wound, 
and  is  said  to  have  sa\'ed  the  life  of  Artaxerxes  when  he  was  left 
for  dead  by  many  of  his  native  followers  on  the  battlefield  of 
Cunaxa,  where  he  so  nearly  lost  his  crown  to  his  brother,  Cyrus 
the  Younger,  who  was  subsequently  himself  killed  in  this  battle. - 
Now,  more  than  a  hundred  years  before  this,  we  have  seen  that 
Cyrus  the  Great  (559-529  B.C.)  sent  to  Egypt  for  a  physician  for 
the  eyes,  while  Darius  (521-486  B.C.),  one  of  his  immediate  succes- 
sors, made  use  of  Democedes,  the  Greek,  in  preference  to  native 
and  Egyptian  court  physicians. 

I  do  not  know  whether  this  sequence  of  historical  events  in 
medicine  has  any  great  value,  but,  in  connection  with  other  facts, 
it  is  perhaps  significant  of  the  shifting  of  medical  knowledge. 

THE  MEDICINE  OF  THE  PARSEES. 

If  we  have  not  already  had  sufficient  glimpses  of  Chaldean  and 
Assyrian  medicine  we  have  only  to  glance  through  the  "Zend- 
Avesta,"^  the  sacred  book  of  the  Parsees,  to  understand  the  reluct- 
ance of  their  monarchs  to  avail  themselves  of  home  talent.     The 

1  Zeitschrift  fiir  Kcilschriftforschung,  II,  1-3. 

2  Xenophon:   Anabasis  1,  VIII,  27.    Plutarch:   Life  of  Artaxerxes. 
^  Darnistetter:   Sacred  Books  of  the  East,  Vol.  IV,  Part  1. 


THE  MEDICINE  OF  THE  TALMUD  27 

remedies  of  the  ancient  Parsees  consisted  chiefly  of  charms  and 
spells.  They  divided  medical  practitioners  into  three  groups: 
Those  who  healed  with  the  knife,  those  who  used  herbs,  and  those 
who  practised  spells  and  incantations,  and  the  "Zend-Avesta" 
recommends  the  latter  class,  not  an  anomalous  proceeding  in 
ecclesiastical  advice  of  later  time  as  well,  but  it  gives,  perhaps,  a 
very  good  reason,  viz.:  They  were  apparently  the  least  to  be 
feared.  ^Ye  learn  that  one  of  their  evil  deities  created  99,999 
diseases  with  which  to  plague  mankind.  Out  of  this  large  number 
we  find  no  mention  of  those  of  the  upper  air  passages,  nor  of  any 
other  dift'erentiation  that  is  intelligible  to  us. 


THE  MEDICINE  OF  THE  "TALMUD." 

There  are  a  number  of  modern  treatises  upon  the  medical  knowl- 
edge of  the  "Talmud,"  but  a  perusal  of  them,  while  it  reveals  a 
perhaps  interesting  state  of  early  Hebrew  sanitary  science,  does 
not  give  us  much  insight  into  their  knowledge  of  diseases  of  the 
nose  and  throat.  There  are  several  references^  to  acute  inflamma- 
tions of  the  throat  which  seem  to  bespeak  the  existence  among  the 
Babylonian  Jews  of  diphtheria,  or  of  that  disease  described  later 
by  Aretaeus  as  Syriac  ulcer,  from  which  "they  died  the  most 
terrible  death  of  all"  the  903  deaths  possible.  This  passage  reminds 
one  of  the  mention  of  the  number  of  diseases  in  the  "  Zend-Avesta." 
We  are  still  further  reminded  of  Chaldean  medicine  by  the  incanta- 
tions spoken  of  as  therapeutic  measures,  of  demons  as  etiological 
factors  in  fatal  throat  inflammations,  and  of  the  dung  of  a  white 
dog  mixed  with  myrrh  as  a  local  throat  application  in  cases  of 
coryza.  Cynanche  and  "tumor  of  the  palate"  (apparently  quinsy) 
are  also  mentioned. 

In  the  ]Mischna-  (Fol.  42)  we  learn  that  transverse  division  of 
the  trachea  is  fatal,  Init  (Holin,  Fol.  45)  that  longitudinal  section 
is  not,  if  there  remains  an  unsevered  portion  at  the  top  and  bottom. 
In  the  "Ghemara"  (Holin,  Fol.  57)  it  is  stated  that  a  hole  in  the 
trachea  may  be  stopped  by  an  artificial  contrivance.  It  appears 
that  they  learned  these  facts  from  their  sacrificial  practice  on 
animals.  In  the  "  Kethubot"  treatise  occurs  this  passage :  "  Samuel 
says  that  the  polyp  shows  itself  by  a  bad  smell  of  the  nose.  A 
'beraitha'  says  the  odor  comes  from  the  mouth."  Evidently 
Samuel  and  the  "beraitha"  meant  ozsena,  although  in  a  footnote 
the  translator  seems  to  think  otherwise.^ 

1  Bergel:     Die  Medizin  der  Talmudistoii,  Leipzig,  1885,  pp.  33,  37,  42,  5L 

2  La  Aledizin  du  Talmud.    Rabliinowitz. 

3  Being  entirely  ignorant  of  Hebrew  and  Sanskrit,  I  have  had  to  relj-  on  the 
authority  of  translations  which  have  been  sharply  criticised,  but  I  have  taken 
some  pains  to  verify  the  above  extracts  from  the  Talmud.  The  Jews  are  said, 
I  know  not  on  what  authority,  to  have  been  ignorant  of  medicine  until  their 
introduction  into  Egypt. 


28  HINDU  MEDICINE 


HINDU  MEDICINE. 

^Yhen  we  begin  to  search  the  writhigs  of  the  ancient  Hinchis  we 
enter  a  mysterious  reahn  full  of  surprises,  finding  therein  many 
medical  facts  which  seem  to  belong  to  a  later  period  of  the  evolu- 
tion of  the  art.  Finding  these  at  a  date  many  centuries  liefore 
the  beginning  of  the  records  of  the  Greeks,  vouches  by  itself  for 
the  remoteness  of  the  beginning  of  Hindu  civilization.  That  their 
writings  are,  some  of  them,  of  immense  antiquity  seems  evident, 
and  that  they  are  the  origin  of  much  which  is  to  be  found  in  the 
later  scientific  literature  of  the  Greeks,  seems  very  probable,  for  it 
is  unreasonable  to  suppose  that  Greek  civilization  was  as  indigenous 
as  they  claimed  both  for  it  and  for  their  race.  Whatever  was  the 
origin  of  the  Hellenic  tribes,  it  is  becoming  yearly  more  evident 
with  the  advance  in  archaeological  knowledge  that  their  learning 
was  transplanted  at  a  comparatively  high  state  of  development 
from  the  land  of  the  lotus  flower,  and  in  all  probability  from  that 
mysterious  table-land  of  Central  Asia,  the  roof  of  the  world,  through 
the  people  which  dwelt  along  the  Ganges  and  the  Eui)hrates  to 
the  shores  of  the  Aegean;  but  while  at  its  source  scientific  knowl- 
edge seems  to  have  stood  still  in  historical  times,  it  has  blossomed 
in  other  soil  to  the  fruition  we  now  enjoy.  It  may  be  conjectured 
that  the  reason  for  this  non-progressive  character  of  the  knowledge 
of  the  Oriental  lies  in  racial  characteristics,  and  yet  it  is  difficult 
from  our  ignorance  of  their  historv  to  understand  whv  this  halt 
in  the  evolution  of  their  knowledge  should  have  occurred  after  it 
had  grown  to  the  proportions  we  recognize  in  the  Susruta.'  The 
contention  of  Haas,-  a  German  critic,  that  the  writings  of  the 
Hindus  show  that  they  have  never  been  a  progressive  race,  but 
that  they  had  borrowed  their  knowledge  from  the  Greeks  without 
developing  it,  is  plausible  when  we  consider  how  eagerly  the  Persian 
monarchs  sought  medical  aid  from  that  source  rather  than  from 
the  East.  The  Hindus,  however,  were  further  removed  from  the 
Persian  monarchs  than  were  the  Greek  cities  of  Asia  Minor,  which 
indeed  formed  a  part  of  their  cm])ire.  Perhaps  the  strongest 
argument  against  this  assum])tion  is  the  fact  that  the  same 
non-progressiveness  is  seen  in  Egyptian  civilization,  and  yet  the 
"Papyros  Ebers"  and  other  evidences  prove  that  a  comparatively 
high  state  of  medical  knowledge  existed  in  Egypt  at  a  i)eriod  even 
anterior  to  the  date  assigned  by  the  Greeks  to  the  Trojan  war, 
and  at  least  many  hundred  years  before  the  birth  of  Plippocrates. 

'  Guizot  and  Freeman  both  ascribe  the  stationary  condition  of  Eastern  civili- 
zation to  the  unison  of  the  temporal  and  spiritual  powers,  but  this  scarcely 
satisfies  us,  and  while  admitting  the  strong  ])robability  of  the  efficiency  of  this 
factor,  we  instinctively  look  for  other  causes  concomitant  and  anterior  to  it. 

'  Haas:  Zeitschrift  der  Deutschen  Morgenliindischcn  Gesellschaft,  Vol.  XXX, 
p.  017:  Vol.  XXXI,  p.  647. 


SUSRUTA  AND  HIPPOCRATES  29 

"  Herodotus'  Histories"  are  sufficient  evidence  on  this  score.  Never- 
theless Haas  attempts  to  show  that  the  medical  writings  of  the 
Hindus  are  of  recent  origin :  in  fact,  that  they  were  composed  at  a 
period  subsequent  to  that  in  which  the  various  Hippocratic  treatises 
were  given  to  the  world. 

Susruta  and  Hippocrates. — Haas  goes  still  further  and  asserts 
that  in  all  probability  the  Susruta  is  really  a  derivative  of  the 
Hippocratic  system,  and  even  that  the  name  "Susruta"  is  a 
Hindu  corruption  of  Hippocrates.  It  is  supposed  b}'  him  that  the 
Hippocratic  writings  were  rapidly  disseminated  through  Asia  and 
India  by  the  Greek  physicians,  who  were  in  such  demand  at  the 
courts  of  the  Eastern  kings,  but  in  the  accounts  of  i\.lexander's 
campaigns  will  be  found  notices  of  Oriental  physicians  who  possessed 
such  knowledge  of  various  parts  of  physic  as  were  unknown  to  the 
army  doctors,  especially  in  regard  to  the  cures  for  the  bites  of 
venomous  serpents,  which  is  perhaps  not  very  conclusive  evidence 
of  a  more  extensive  knowledge.  Nevertheless  in  reading  the 
Susruta  and  the  Charaka  one  will  be  much  impressed  by  some 
striking  analogies  to  passages  in  some  of  the  Hippocratic  books 
which  seem  not  to  have  been  transmitted  through  generations,  but 
to  have  been  directly  transferred  from  one  treatise  with  very  little 
modification  to  the  other.  Which  was  the  original  in  nowise 
appears.  It  is  scarcely  necessary  to  say  that  Haas'  arguments 
have  not  been  generally  accepted  as  convincing. 

At  any  rate,  since  the  dawn  of  history,  western  medical  knowledge 
blown  on  the  wings  of  the  wind  from  European  lands  has  scarcely 
produced  a  ripple  on  the  stagnant  pool  of  Hindu  medicine,  and 
today  the  two  systems  in  India  are  practised  side  by  side. 

In  the  Talmud  we  have  seen  a  reference  to  wounds  of  the  car- 
tilages of  the  larynx  and  we  again  meet  it  in  the  Hig  Veda  and  the 
Susruta. 

India  is  referred  to  in  the  Rig  ^  eda  as  the  Bountiful  One  who 
without  a  ligature  can  cause  the  wind-pipe  to  reunite  when  the 
"cervical  cartilages"  are  cut  across,  provided  they  are  not  entirely 
severed.^  Thus  early  do  we  find  a  statement  which  refers  to  a 
point  discussed  for  more  than  1500  years  after  the  beginning  of 
the  Christian  era  in  the  history  of  tracheotomy. 

The  Hindu  "Ayurvedas,"  just  as  the  medical  knowledge  of  all 
ancient  peoples,  were  supposed  to  be  of  divine  origin.  Even  in 
modern  times  the  Christian  Scientists  and  their  ilk  remind  us 
of  this  tendency.  The  "Ayurveda  of  Susruta"  was  revealed  by 
D'hanvantare,  the  i)hysician  of  the  gods,  out  of  compassion  for 
the  suffering  of  mortal  men.    These  medical  vedas  or  axioms  were 

1  Hornle:  Studies  in  Ancient  Indian  Medicine.  The  Journal  of  the  Royal 
Asiatic  Society  of  Great  Britain  and  Ireland,  London,  190(5-09,  \^ol.  II,  ]i.  922. 
See  also  Julius  Jolly:  Zur  Quellenkunde  der  Indischen  Medizin,  Zcitschrift  der 
deutschen  Alorgenliindischen  Gesellschaft,  Leipzig,  19UU,  Vol.  LIV-L\'. 


30  HINDU  MEDICINE 

collected  and  transcribed  by  his  disciple  Susruta.  The  "Ayurveda 
of  Susruta"  is  said  b}-  the  wise  men  of  the  East  to  be  at  least  of  a 
date  1000  years  B.C.,  and  it  contains  scraps  of  medical  lore  which 
bear  every  evidence  of  being  still  more  ancient.  Time  being  of 
little  value  to  the  dreamy  Hindu,  his  chronology  is  a  source  of 
inexhaustible  irritation  to  the  uneasy  Western  savage.  Althougli 
we  of  another  civilization  have  good  reason  for  tracing  our  philologi- 
cal, our  scientific  and  philosophical,  even  our  ethnical  origin,  back 
to  this  cradle  of  antiquity,  we  have  traveled  a  long  distance  since 
then  on  all  these  highways,  and  not  only  is  the  language  obscure, 
but  the  ideas  are  many  of  them  unintelligible  to  us  in  their  old 
books.  Therefore,  althoush  the  "Susruta"  is  admirably  arranged 
in  captions  much  in  accord  with  modern  medical  ideas,  the  Latin 
translation  of  Hessler  (1844)  is  in  many  places  confusing,  and  it 
is  perfectly  evident  that  the  translator  is  often  himself  groping 
in  the  dark. 

There  are  to  be  found  in  the  "Susruta,"  and  easily  referred  to 
in  Hessler's  rendering,  many  references  to  the  diseases  of  the  nose 
and  throat,  some  of  them  recognizable  by  our  barbaric  ^Yestern 
intellect,  but  many  of  them  to  us  quite  vague. 

Charaka  Samhita. — The  Charaka  Samhita  is  being  translated 
from  Sanskrit  into  English  by  Avinash  Chandra  Kaviratna,  a 
learned  pundit  of  Calcutta.  This  work  is  said  by  the  Hindus  to  be 
a  revelation  of  Indra,  the  god  of  the  middle  air,  through  Charaka 
the  sage,  and  is  said  to  be  of  much  more  ancient  origin  than  the 
compilation  of  "Susruta."  At  least  it  is  more  unintelligible  to  the 
modern  student  of  medical  history.  To  the  student  of  philology 
it  is  said  by  Wise  and  Miiller,  and  Eastern  scholars  generally,  to 
be  of  greater  value  than  the  "Susruta,"  and  the  learned  and 
enthusiastic  translator,  a  patriotic  Hindu,  indulges  in  the  fond 
hope  that  by  the  diffusion  of  the  wisdom  of  Charaka  a  profound 
impression  may  be  made  upon  the  practice  of  the  medical  art  as 
pursued  by  the  energetic  sons  of  the  West,  the  physicians  of  Europe 
and  America.  I  am  afraid  our  Hindu  confrere  does  not  realize 
the  obduracy  of  the  seed  of  Japhet. 

Both  in  the  "Susruta"  and  in  the  "Charaka"  the  declaration  is 
made,  and  this  is  found  very  little  modified  in  the  medical  works 
of  the  Greeks,  that  "Whid,  bile,  phlegm  have  been  said  to  be  the 
cause  of  all  bodily  disease."  What  follows,  however,  I  have  not 
noted  among  the  writings  of  the  Greeks.  It  is  a  little  too  mystic 
for  them,  apparently.  "The  qualities  of  passion  and  darkness 
have  again  been  indicated  to  be  the  causes  of  mental  diseases." — 
("Charaka.") 

In  "Susruta"  we  learn'  that  there  are  sixty-four  diseases  of  the 
mouth  in  seven  situations.     The  seats  of  morbid  action  are  the 

1  Susrutas:  Ex  Sanskrita  in  Latinum:  F.  Hessler.  Erlangae,  1844-55,  Tom. 
I,  p.  202. 


UVULOTOMY  AND   TONSILLOTOMY  31 

lips  (8  diseases),  roots  of  the  teeth  (15),  the  teeth  (8),  the  palate 
(9),  the  fauces  (17)  and  all  of  them  together  (3).^ 

As  one  of  the  diseases  of  the  palate  we  recognize  quinsy  in  Hess- 
ler's  Latin:  "Tumor  rigidus,  in  palati  regione  a  sanguine  ortus 
existit.  Cognoscendus  est  hie  morbus  angina,  febre  dives."  There 
are  various  passages  translated  by  Hessler  which  Morell  ^Mackenzie 
supposes  to  refer  to  diphtheria,  but  I  doubt  if  we  can  differentiate 
the  different  forms  of  acute  throat  inflammation,  accounts  of 
which  are  found  here,  as  elsewhere,  in  all  extensive  treatises  of  the 
ancients  on  disease,  it  matters  not  to  what  age  or  people  they 
belong. 

One  cannot  but  be  struck  by  the  early  tendency  of  the  medical 
man  to  lay  great  stress  and  emphasis  on  a  name.  We  ha\'e  seen 
how  the  physician  of  Egypt  was  to  announce  the  presence  of  a 
"fatty  tumor  in  the  neck,"  and  here  in  the  "Susruta"  the  rendering 
is:  "Qui  tumor  in  linguae  dorso  magnus  est,  is  intumescentia 
vocatur."  We  may  readily  imagine  that  these  venerable  doctors 
of  the  hoary  past  made  use  of  some  recondite  word  of  a  language 
still  older  than  their  own,  if  any  such  there  were,  to  express  in 
suitably  dignified  terms  for  the  edification  of  the  laity  a  diagnosis 
w^hich  was  really  only  a  definition,  "  Un  specieux  babil,  qui  vous 
donne  des  mots  pour  des  raisons,"  as  Moliere'  puts  it  2500  years 
later. 

Uvulotomy  and  Tonsillotomy. — Here  and  there  we  can  recognize 
familiar  surgical  operations.  "By  means  of  forceps  between 
thumb  and  finger,  drawing  the  u\'ula  forward,  the  physician  may 
cut  it  with  a  sickle-shaped  knife  above  the  top  of  the  tongue." 
"Gilagum  (quinsy?),  so-called,  may  be  cured  by  the  knife."  Firm, 
hard,  and  filling  the  fauces,  extraordinarily  swollen  with  sprouting 
flesh,  giving  rise  to  much  pain,  caused  by  the  evil  inflammation  of 
the  humors,  killing  almost  a  hundred  men,  it  is  recognized  that 
(this?)  swelling  of  the  tonsils  is  incurable;  but  a  tumor  seen  in  the 

1  The  statement  is  made  by  Galen — "Galeni  in  Hippocratis  Librum  de 
Alimento  Commentarius,"  III,  XXVI  (Opera  omnia  [Klihn]  Lipsia?,  1821-33; 
XV,  p.  363) — that  the  school  of  Cnidos,  the  rival  of  that  of  Cos,  divided  diseases 
into  a  great  number  of  different  kinds:  "Seven  diseases  of  the  bile,  twelve 
diseases  of  the  bladder,  four  diseases  of  the  kidneys,"  etc. 

If  we  consult  the  ideas  and  the  philosophy  of  Pythagoras  (500  B.C.),  which 
had  a  profound  effect  upon  Greek  civilization  and  had  a  great  influence  at  the 
school  of  Cnidos,  we  will  find  in  them  traces  of  much  which  he  derived,  evidently 
from  liis  long  travels  and  his  dihgont  studies  pursued  among  the  Oriental 
nations  with  which  Greek  tradition  crecHts  him.  Now  this  reverence  for  num- 
bers we  find  in  the  Charaka  and  Susruta,  and  we  have  ah'cady  noted  it  in  the 
Zend-Avesta  and  in  the  Talmud  in  connection  with  diseases.  It  is  by  many 
little  hints  such  as  this  that  we  are  able  to  trace  the  connection  of  Greek  med- 
icine with  that  of  the  Orientals,  and  we  may  also  note  how  the  latter  have 
purified  and  exalted  it,  not  only  by  their  initative,  but  bj-  the  dropi)ing  of  the 
superstitions  with  which  it  was  overgrown.  There  is  very  little  of  spells  and 
incantations,  and  reverence  for  numbers  and  malignant  demons,  to  be  found 
in  the  Hippocratic  writings. 

2  Malade  Imaginaire. 


32  HINDU  MEDICINE 

throat  about  the  size  of  the  seed  of  the  Phylhinthus  Emblica, 
stationary,  a  Httle  painful,  made  up  of  phlegm  and  blood,  adherent 
like  the  fruit  of  the  Terminalia  Alata,  this,  curable  by  the  knife, 
is  called  Gilagu."  Are  we  here  to  recognize  a  differentiation  of 
malignant  and  benign  swelling  of  the  tonsils  and  the  prevalence 
of  the  practice  of  tonsillotomy? 

Wise,^  in  his  "Hindu  System  of  jNIedicine,"  describes  a  method 
of  abscission  of  the  tonsils  which  aimed  at  removing  a  third  part 
only  with  the  knife.  "  If  all  is  cut  the  patient  will  die  of  hemor- 
rhage." As  he  does  not  give  his  reference  I  am  uncertain  if  this 
is  contained  in  the  more  ancient  books  or  not.  ]\Iany  more  recent 
writers  have  insisted  that  a  partial  excision  only  is  ever  indicated, 
and  is  sufficient.  We  may  be  sure  from  these  passages  that  they 
knew  what  secondary  tonsillar  hemorrhage  meant  as  well  as  some 
of  the  rest  of  us. 

Rhinoplasty. — It  is  especially  in  the  Hindu  writings  that  we  find 
such  complete  and  minute  accounts  of  the  various  plastic  operations 
about  the  nose.  This  was  due,  doubtless,  to  the  practice  of  the 
wrathful  Oriental  potentates  who  amputated  the  nose  out  of 
revenge  or  in  the  exercise  of  judicial  penalties.  This  art  was  almost 
entirely  forgotten  by  the  Greeks,  because  they  shrank  in  horror 
from  the  mutilation  of  the  human  form,  and  had  little  opportunity 
to  practise  plastic  operations  for  its  correction.  In  a  more  savage 
age  and  country,  many  centuries  later,  it  was  revived  by  Taglia- 
cozzi,  but  we  shall  easily  trace  it  back  to  its  Oriental  source. 

^'aporization  and  fumigation  through  a  tube  were  frequently 
emj)loyed  in  the  diseases  of  the  nose  and  throat.  Stimulating  and 
acrid  vapors  seem  to  have  been  recommentled  in  what  we  may 
conjecture  was  oza?na.''  It  was  also  prescribed  for  coughs,  asthma, 
hoarseness,  mucous  discharges  and  enlargement  of  the  tonsils,  but 
as  it  was  also  advised  for  "mor})id  baldness  and  a  reddish  yellow- 
ness of  the  hair,"^  one  is  left  in  some  doubt  as  to  its  modus  operandi. 
These  diseases  were  all  due,  according  to  the  sage,  to  the  same 
cause.  Local  applications  of  ointments  were  made  to  the  nostrils 
and  various  sternutatories  were  used  for  cleansing  the  nasal 
chambers,  after  which,  apparently  in  coryza,  the  following  directions 
were  explicit,  and  could  be  only  slightly  inii)roved  by  the  modern 
rhinologist:  The  patient  was  to  lie  on  his  back,  raise  the  tip  of  his 
nose  with  his  index  finger  and  allow  his  physician  to  drop  in  his 
nostrils  warm  oleaginous  liquids.  While  this  w^as  being  done  he 
was  not  to  become  angry,  nor  speak,  nor  laugh,  nor  swallow  the 
oil  dripping  from  his  nose,  but  s])it  it  out.  The  use  of  sternutatories 
or  snuffs  was  also  recommended  for  sleeplessness  and  clearing  the 

'  Wise,  T.  A.:   Commentary  on  the  Hindu  System  of  Medicine.     Calcutta, 
184.5. 
2  Susruta  (Hessler),  Therapia,  Cap.  XXII-XL. 
'  Cliaraka.     (Trans,  by  Kaviratna.)     Calcutta. 


RHINOPLASTY  33 

head  in  the  morning — apparently  prescribed  for  conditions  in 
which  we  order  douches  and  sprays.  Gargles  were  also  a  part  of 
their  therapeutical  resources.  They  very  often  used  oil  as  a  men- 
struum, and  apparently  had  a  more  thorough  way  of  using  the 
gargle  than  we  usually  insist  upon.^  It  is  evident  that  these  old 
Hindus  recognized  the  dependence  of  laryngeal  or  nasal  diseases, 
as  is  apparent  in  this  sentence  in  Hessler's  translation:  "Nasale 
remedium  morbos  hominum  supra  claviculam  ortos  refrenat  et 
organa  sensuum  pura  atque  os  suaveoleus  efficere  potest." 

In  the  light  of  recent  sanitary  doctrines  and  regulations  the 
following  quotation  from  Charaka  (p.  74)  may  })e  of  interest: 
"One  should  not  eject  the  mucus  or  phlegm  of  one's  nose  in  a 
place  that  is  crowded."  This,  however,  may  have  been  only  a 
precept  of  social  intercourse  rather  than  having  the  additional 
sanitary  weight  it  now  possesses.  At  this  place  occurs  rather 
frank  advice  as  to  the  relations  between  man  and  wife.  They 
are  amusing,  but  perhaps  a  little  out  of  place  now  in  print  when 
not  attended  by  the  strict  scientific  necessity  for  their  publica- 
tion. The  one  precept  which  may  be  quoted  here  is  as  applicable 
to  laryngologists  and  rhinologists  as  it  is  to  the  rest  of  mankind. 
It  is  to  the  effect  that  a  man  should  make  a  confidante  of  his  wife, 
but  he  should  not  tell  her  all  his  secrets.  These  little  scraps  from 
the  dim  and  misty  past  of  a  forgotten  civilization  make  one  realize 
the  universal  brotherhood  of  man.  In  fact,  one  cannot  even  glance 
through  the  works  of  Charaka,  and  especially  of  Susruta,  without 
having  one's  mind  impressed  with  the  antiquity  of  human  knowl- 
edge and  wisdom,  and  it  is  a  vast  education  for  any  man  when  he 
can  be  brought  to  realize,  in  this  egotistical  epoch,  how  little  of  it 
after  all  has  had  its  origin  in  his  day  and  generation. 

We  can  only  conjecture  that  the  development  of  the  arts  and 
sciences  of  the  ancient  Oriental  world  must  have  occurred  chiefly 
in  some  prehistoric  cycle  of  human  acti^'ity,  when  man's  mind 
and  body  were  as  free  along  the  Ganges  as  they  were  on  the  shore 
of  the  ^Egean  when  the  Hellenic  tribes  took  up  the  torch,  in  the 
blazing  light  of  which  we  still  live.  This  is  what  liberty  means, 
and  we  can  now  see  along  the  Ganges  and  on  the  ^Egean  the 
results  of  the  mental  and  political  slavery  not  only  of  an  Oriental, 
but  of  a  once  glorious  Occidental  race.  Kassel-  quotes  from  Susruta 
a  passage,  which  apparently  I  have  missed,  in  which,  to  judge 
from  the  description,  there  is  very  good  evidence  that  syphilitic 
disease  not  only  of  the  genitals  but  of  the  nose  was  well-known  to 
the  Hindus. 

In  Wise's  work  on  "Hindu  Medicine,"^  from  which  I  now 
quote,  there  are  many  accounts  of  nose  and  throat  diseases  which  I 

1  Susruta  (Hessler):  Tomus,  III,  p.  42. 

2  Die  Nasenheilkunde  des  Altertums,  p.  20.  '  Loc.  cit. 

3 


34  HINDU  MEDICINE 

cannot  find  or  have  inadvertently  passed  over  in  the  translations  of 
the  "Charaka"  and  of  the  "Susruta"  at  my  disposal.  As  he  states 
that  his  work  is  taken  exclusively  from  the  ancient  Hindu  writings, 
althoiiii'h  in  the  passages  cited  he  does  not  indicate  the  sources 
from  which  he  draws  his  information,  it  mav  be  inferred  that  thev 
are  of  equal  antiquity  with  those  I  have  drawn  directly  from  the 
translations  of  Hessler  and  Kaviratna.  ^Moreover,  I  recognize  in 
Wise's  book  many  passages  identical  witli  those  in  the  "Charaka" 
and  "Susruta." 

^ledicines  administered  by  fumigation  through  the  nostrils 
were  used  not  only  for  local  nasal  diseases,  but  for  some  general 
affections,  and  particular  directions  are  given  for  using  them. 
Among  the  errhines  or  sternutatories  to  clear  the  head  may  be 
noted  pepper,  mustard,  orris,  ginger,  asafoetida.  One  might  think 
they  would  be  efficient.  One  of  the  methods  recommended  for 
causing  sneezing  was  to  look  at  the  sun  so  that  its  rays  would  fall 
on  the  mucous  membrane  of  the  nostrils.  We  recognize  here  an 
error  in  mistaking  a  reflex  phenomenon  of  the  retina  for  a  direct 
action. 

Among  the  gargles,  besides  the  more  agreeable  ones  of  oil, 
vinegar,  honey,  and  the  juices  of  fruits,  the  urine  of  cows  finds  a 
place.  Stimidating  and  irritating  substances  (pepper)  were  also 
prescribed  as  gargles.  There  is  an  instrument  spoken  of  (p.  169) 
for  "eradicating  nasal  polypi;  a  frequent  and  troublesome  disease 
in  many  parts  of  Hindustan."  It  seems  to  have  been  some  sort 
of  a  curette. 

Foreign  Bodies. — (p.  186.)  If  a  foreign  body  is  "in  the  throat,  the 
extraneous  matter  may  be  discharged  by  thrusting  down  a  hot 
iron  to  dissolve  it,  or  soften  it,  and  so  remove  it.  In  such  case  the 
hot  iron  is  passed  through  a  metallic  tube.  A  probang  for  removing 
fish  bones  is  usual;  by  drinking  fluids  and  emetics  it  is  also  dis- 
lodged; this  may  also  be  done  by  beating  the  patient  upon  the 
back  of  the  neck."  Among  the  fifteen  modes  of  removing  extra- 
neous substances,  Bidmapana  is  "by  blowing,  as  a  substance  intro- 
duced into  the  larynx,  which  produces  great  irritation  and  strong 
efforts  at  coughing,"  etc.  Pramarsa:  "If  in  the  nostrils,  errhines 
are  to  be  used."  It  must  be  confessed  that  the  art  of  removing 
foreign  bodies  from  the  upper  air  passages  does  not  seem  to  have 
been  very  highly  developed,  and  the  above  described  use  of  the 
hot  iron  seems  strange  and  hardly  credible.  Is  it  possible  that 
we  have  here  a  confused  Hindu  rendering  of  the  recommendation 
by  Hippocrates  for  the  use  of  the  hot  iron  in  the  nose?^ 

Fracture  of  the  Nose. — We  are  reminded  of  Hippocrates  in  the 
passage  (Wise,  j).  192) :  "When  the  bones  of  the  nose  are  depressed 
they  are  to  be  raised  into  their  natural  position  by  means  of  an 

^  Diseases  II,  where  much  else  resembles  the  Susruta. 


PRE~HIPPOCRATIC  MEDICINE  IN  GREECE  35 

instrument  called  Shalaka:  a  hollow  wooden  tube  is  kept  in  the 
nostrils  so  as  to  retain  the  bones  in  their  natural  position."^  We 
may  note  another  passage,  and  this  is  especially  dwelt  on  by  Haas 
(/.  c.)  as  indicative  of  the  corrupt  and  degenerate  derivation  of 
Hindu  medicine  from  the  Greeks.  There  is  probably  no  quotation 
from  Hippocrates  so  well  known  as  that  in  which  he  describes  the 
facies  of  approaching  death  (Prognostics  2):'-  "A  sharp  nose, 
hollow  eyes,  collapsed  temples;  the  ears  cold,  contracted,  and 
their  lobes  turned  out;  the  skin  about  the  forehead  being  rough, 
distended  and  parched;  the  color  of  the  whole  face  being  green, 
black,  livid,  or  lead-colored."  Now  compare  this  with  Wise's 
translation  from  the  "  Susruta" :  "  When  it  [the  nose]  becomes  pale, 
dry,  and  shining,  and  is  turned  to  one  side;  the  nostrils  extended, 
dry,  and  dirty,  and  the  passage  of  the  air  produces  a  noise;  or  when 
the  point  of  the  nose  retracts  and  is  flattened  with  weakness  and 
depression,  the  person  will  soon  die."  We  note  how  distinctly 
inferior  this  is  to  the  graphic  description  of  the  Greek  sage.  I 
doubt  very  much  the  conclusiveness  or  even  the  suggestiveness 
of  the  passage  in  the  "Susruta"  as  an  argument  for  the  derivation 
of  Hindu  from  Greek  medicine.  Similar  phenomena  were  observed 
by  men  of  dissimilar  mental  powers. 

There  are  thirty-one  diseases  of  the  nose.  Simple  catarrh, 
acute  and  chronic,  was  called  Pinasa.  Ozsena  is  Putinaska.  Nasal 
polypi  were  termed  Nasarsah  and  there  were  four  kinds.  Tumors 
of  the  nostrils  are  of  five  kinds  and  were  called  Nasarbuda,  but  it 
does  not  appear  how  they  were  distinguished  from  the  nasal  polypi 
(Wise,  p.  289).  Goitre,  tumors  of  the  neck,  scrofulous  swellings, 
hoarseness,  asthma,  cough  are  all  described,  but  there  is  little  in 
the  passages  which  is  either  interesting  or  instructive.  We  may 
pass  lightly  over  the  Hindu  conception  of  anatomy  and  physiology. 
As  an  indication  of  its  limitations,  Wise,^  among  other  examples 
of  their  ignorance,  declares  that  the  Hindus  had  but  one  name  for 
throat,  "Khunt,"  including  in  its  signification  not  only  the  air-way 
but  the  gullet. 


PRE-HIPPOCRATIC  MEDICINE  IN  GREECE. 

Whatever  may  have  been  the  truth  as  to  the  derivation  of  Hindu 
medicine,  we  have  little  actual  means  of  knowing  whence  the 
Greeks  drew  the  germs  of  their  medical  knowledge.  We  may 
conjecture  that  it  came  with  the  Phoenician  trading  vessels  from 
the  shores  of  Asia,  or  the  Hellenic  tribes  may  have  brought  it  from 

1  Vid.  Susruta  (Hessler),  Tomus,  II,  p.  67. 
-  Genuine  works  (Adams),  1,  p.  195. 

^  Review  of  the  History  of  Medicine  (among  the  Asiatics),  London,  1867,  I, 
p.  135. 


3G  PRE-HIPPOCRATIC  MEDICINE  IN  GREECE 

the  Asiatic  tal)le-lantls  with  tlicin,  but  more  prol)al)ly  much  the 
larjjcr  portion  of  it  came  directly  from  the  \ailey  of  tlie  Nile  when 
in  (iTO  B.C.  the  land  of  the  lotus  fiower  was  thrown  open  to  Greek 
commerce  and  Greek  curiosity.  Thales  and  Pythagoras  are 
significant  personages  in  the  early  history  of  Greek  science.  In 
the  fragments  of  their  philosophy  as  well  as  in  the  legends  of  their 
lives  we  find  unmistakal)le  evidences  of  their  sojourn  among  the 
Orientals  and  of  their  absor})tion  of  Oriental  civilization  and 
philosophy.    The  same  may  be  said  of  Solon. 

Perhaps  it  may  be  of  some  value  to  note  tliat  therai)eutics  in 
Greek  medicine  include  none  of  the  disgusting  substances  and 
scarcely  any  of  the  charms  and  invocations  which  mark  so  strongly 
that  division  of  medicine  among  the  Egyptians,  Chaldeans,  Hindus, 
and  Eastern  races  generally,  and  which  we  have  seen  later  was 
introduced  into  the  Greek  medical  writings  of  the  Roman  Empire 
and  upon  which  I  have  already  commented. 

The  period  of  four  hundred  or  fi\e  hundred  years  which  stretches 
from  the  supposed  age  of  Homer  to  the  birtli  of  Hippocrates  (4(10 
B.C.)  is  one  of  which  we  know  but  little  in  the  history  of  medicine. 
It  is  entirely  devoid  of  medical  works  which  ha^'e  come  down  to 
us.  In  philosophy,  Thales,  Xenophanes,  and  Pythagoras  greatly 
influenced  the  minds  of  men  in  weaning  them  from  the  superstitions 
recorded  in  the  "Theogony"  of  Hesiod.  They  winnowed  out  from 
them  idealistic  portions  which  could  be  made  to  stand  as  symbolical 
of  their  own  ideas  of  cosmogony.^  Coming  down  to  the  time  of 
Socrates,  we  find  him  recognizing  things  divine  and  things  material, 
while  Hip])ocrates,  but  little  his  junior,  brings  all  phenomena  under 
one  head  and  calls  them  all  divine,  one  not  more  than  the  other. 
(Airs,  Places,  and  \Yaters.)  Whatever  may  have  been  the  channels 
by  which  were  carried  the  seeds  of  knowledge,  the  mar^■elous  growth 
which  sprang  up  on  the  soil  of  Greece  has  not  ceased  and  will 
never  cease  to  excite  the  wondering  admiration  of  mankind. 

Civilization  in  Greece. — It  is  significant  perhaps  that  the  opening 
of  Egypt  to  Greek  coimnerce  took  place  at  about  the  time  of  the 
beginning  of  written  records  in  Greece  ((300  b.c.),^  and  two  hundred 
years  after  writing  was  first  introduced  and  the  epic  ballads  of 
the  wandering  bards  and  rhapsodists  became  perpetuated  in 
written  records  we  have  the  birth  of  the  "P^ather  of  YIedicine." 
It  needs  only  a  cursory  perusal  of  the  Ilippocratic  writings  to 
realize  how  intense  the  mental  activity  of  nascent  Greek  ci^■ilization 
must  have  been  to  have  i)roduced  in  the  short  period  of  two  hundred 
years  a  condition  which  made  possible  the  comj)ilation  of  these 
masterpieces  of  medicine  in  whose  inspiration  we  still  live.  After 
the  excursions  we  ha^'e  made  into  the  more  stagnant  civilizations 

'  Grotc:  History  of  Greece,  \o\.  I,  p.  3GS  f.  f. 
=  Ibid.,  Vol.  II,  p.  149. 


THE  NOSE  AND   THROAT  IN  HOMER  37 

in  the  search  for  the  origin  of  medical  knowledge  we  feel  that  we 
are  nearing  home,  or  at  least  on  more  familiar  ground,  when  we 
begin  the  study  of  Greek  medical  history.  At  the  port  of  entry 
looms  up,  obscuring  all  others,  the  great  name  of  Hippocrates. 
There  was  medical  knowledge  in  Greece  before  the  birth  of  Hip- 
pocrates, of  course,  but  the  records  of  it  have  perished  and  so 
have  the  works  of  those  who  followed  him.  It  is  only  by  scanning 
secular  literature  and  by  noting  references  in  later  medical  writings 
that  we  are  able  to  obtain  some  glimpses  of  the  state  of  the  knowl- 
edge of  the  anatomy  and  the  functions,  but  scarcely  of  the  diseases 
of  the  upper  air  passages.  In  the  legends  of  the  Hellenic  races 
are  to  be  found  traces  of  familiarity  with  a  medical  art  which 
existed  long  before  the  rise  of  the  school  w^hich  clustered  around 
the  altars  of  Aesculapius  in  the  Isle  of  Cos. 

Ancestry  of  Hippocrates. — Hippocrates^  traced  his  lineage  in 
the  seventeenth  generation  through  a  medical  ancestry  to  that 
demigod  who  according  to  Cicero  (De  Natura  Deorum,  III,  22) 
was  the  son  of  Apollo  or  of  Hermes,  or  of  Arsippus  and  Arsinoe. 
He  w^as  the  first  to  discover  the  probe,  according  to  Greek  legends, 
the  first  to  bandage  a  wound,  the  first  to  teach  men  to  draw  teeth 
and  to  purge  their  bowels.  For  these  and  other  services  he  was 
deified,  but  because  he  raised  the  dead  and  attempted  to  exercise 
his  power  of  making  men  immortal,  he  was  struck  into  Tartarus 
by  the  forked  thunderbolt  of  the  jealous  Olympian  Zeus.  His 
two  sons,  Podaleirus  and  Machaon,  led  the  thirty  Thessalian 
ships  to  the  siege  of  Troy  (Iliad,  II,  731),  where  they  exercised  their 
father's  art  as  well  as  that  of  Mars.  Machaon  was  said-  to  be 
skilled  in  the  arts  of  the  surgeon,  while  Podaleirus  had  "skill  over 
things  invisible,"  and  to  the  latter  was  given  precedence,  a  custom 
still  pre^'ailing  in  medicine  to-day.  It  is  to  ]\Iachaon,  who  knew 
how  to  draw  out  darts,  to  make  incisions,  and  to  treat  wounds  and 
ulcers,  that  the  present  generation  of  rhinologists  owe  homage 
rather  than  to  Podaleirus,  who  diagnosed  madness  in  the  blazing 
eyes  of  Ajax. 

We  can  do  little  more  in  this  period  of  medical  history  than 
seek  out  the  origin  of  the  nomenclature  of  the  parts  of  the  human 
anatomy  with  which  we  are  concerned.  We  have  seen  that  the 
word  nose  is  apparently  contemporaneous  in  origin  with  that  of 
the  Aryan  languages.  While  we  have  the  authority  of  Darcmberg^ 
for  the  statement  that  there  are  only  five  instances  mentioned  in 
Homer's  Iliad  of  wounds  of  the  throat,  there  are  a  large  number 
of  lines  in  which  the  nose  is  mentioned. 

The  Nose  and  Throat  in  "Homer." — We  read  (v.  291)  how  Athene 
directed  the  lance  of  Diomede  so  that  it  jiierced  the  nose  of  Pandarus 

1  Grotc:  History  of  Greece,  Vol.  I,  p.  182. 

-  Arktinus:  (770  b.c.)  Epicc.  Grace.  Fragm.,  II,  p.  22. 

^  La  Mcdecine  dans  Hoinere. 


38  PRE-HIPPOCRATIC  MEDICINE  IN  GREECE 

near  the  eyes,  crashed  past  the  white  teeth  and,  cutting  the  tongue, 
api)oared  under  the  chin,  and  how  the  mortally  wounded  chieftain 
pitched  headlong  from  his  chariot.  There  is  a  line  in  the  Iliad 
which  gives  evidence  that  embalming  was  understood  bv  Homer's 
Greeks  (XIX,  39). 

The  goddess  Thetis  dropped  nectar  and  ambrosia  into  the  nos- 
trils of  the  dead  Patroclus  to  keep  the  skin  hard  and  firm  and 
thus  preserve  the  body.  This  she  does  to  allay  the  grief  of  her 
son  Achilles  at  the  death  of  his  friend.  As  we  know  that  embalm- 
ing was  foreign  to  later  Greek  customs,  we  may  perceive  here  a 
familiarity  at  least  with  Egyptian  practices,  if  not  an  influence 
of  Egyptian  ideas,  and  to  some  extent  the  prevalence  of  oriental 
customs. 

Etymology  of  Greek  Words  for  "Throat." — We  have  seen  how 
indefinite  was  the  Hindu  Mord  for  throat.  Although  the  Greeks, 
unlike  the  Hindus,  had  many  words  for  this  part  of  the  anatomy, 
thev  used  them  at  first  very  indefiniteh'  and  interchangeablv. 
The  word  pharynx  in  early  Greek  literature  was  about  as  indefinite 
as  our  word  throat.  It  occurs  in  Homer's  Odyssey  first.  If  you 
will  turn  to  the  graphic  description  of  that  horrible  man-eating 
Cyclops,  Polyphemus,  in  the  ninth  book,  at  line  373,  you  will 
find  the  word  there  used  in  describing  how,  after  eating  a  brace 
of  Greeks  and  swilling  barrels  of  wine,  the  bloody,  swinish  giant 
fell  over  in  drunken  stupor  on  his  back  in  the  ca^'e  while  wine  and 
morsels  of  his  cannibalistic  feast  regurgitated  from  his  capacious 
pharynx  (Odyssey,  IX,  373). 

(f)do'jyo~  (Js^saauTO  oiuo^  (^>coiw(  zaijophnzot. 

Whether  this  is  the  first  written  us(>  of  the  word  or  not,  it  certainly 
occurs  here  in  a  most  vividly  striking  passage  of  the  greatest  of 
poems  by  the  first  of  poets.  It  will  be  seen  that  Homer  has  used 
the  word  here  in  accordance  with  its  present  significance,  but 
in  the  Odyssey  again  (XIX,  480),  Ulysses  grasps  with  his  right 
hand  the  4>dyj^  (throat)  of  Euryclea  to  prevent  her  crying  out. 
Even  in  the  works  of  IIipi)ocrates  a  similar  looseness  of  meaning 
is  to  be  observed,  as,  for  instance,  in  the  Littre  edition,^  where 
the  translator  renders  the  word  as  larynx.  Galen,-  however,  in 
his  comments  on  Hippocrates,  declared  that  by  the  term  pharynx 
the  latter  understood  that  region  which  is  situated  in  front  of  the 
gullet  and  win(l-i)ipe  and  which  may  be  inspected  by  dc])ressing 
the  tongue. 

The  word  larynx  is  not  found  in  Homer,  l)ut  is  first  noted  among 
the  dramatic  poets;  but  here  again  quite  indefinitely  arousing 
our  suspicion  that  /dnu^  may  have  been  at  first  a  corruption  and 

'  Oouvrcs  completes  d'Hippocrate,  Trad.  i)ar.  E.  Littre',  Paris,  1839-1)1,  \"11I, 
p.  505. 
2  Opera  Omnia  (Kuhn,  XVIII,  pars  II,  ]).  264). 


DRINK  IN  THE  LARYNX  39 

a  tautological  use  of  the  word  (f^dou^.  This  may  be  seen  by  a 
reference  to  the  plays  of  Aristophanes  (The  Knights,  I,  1363;  The 
Frogs,  I,  575).  In  the  Cyclops  of  Euripides  (I,  157)  occurs  the 
passage,  fi(ou  too  Aafniyya  osexaua^i  aou,  which  the  dictionary  trans- 
lates, "Has  aught  run  gurgling  through  thy  throat?" 

Drink  in  the  Larynx, — The  thought  arises  from  this  quotation 
that  the  idea  of  the  drink  going  into  the  larynx  must  have  originally 
arisen  from  the  resonance  of  the  larynx  and  trachea  transmitting 
the  sound  of  the  swallowed  liquid  from  the  oesophagus.  This 
might  have  been  still  further  strengthened  by  the  sight  of  the 
movements  of  the  larynx  in  the  act  of  deglutition.  Hippocrates, 
however,  will  be  found  to  use  the  word  more  correctly  when  refer- 
ring to  results  of  the  division  of  the  wind-pipe  (Des  Chairs,  IS),^ 
and  in  the  chapter  (De  la  Nature  des  Os,  1)^  where  he  describes 
how  the  larynx  goes  to  the  lungs  and  thence  to  the  top  of  the 
bladder,  but  even  as  late  as  Galen  the  two  terms  were  occasionallv 
used  interchangeably.  Aristotle  also  uses  the  word  in  its  present 
signification  and  only  rarely  speaks  of  the  wind-pipe,  i.  e.,  the 
trachea,  as  extending  from  the  lungs  to  the  mouth.  Not  until 
Galen,  however,  do  we  find  the  term  definitely  established  by  his 
anatomical   descriptions. 

Homer  uses  the  word  Aa4)an(lyo::  once  in  the  Iliad  (XXII,  328), 
as  a  similar  but  more  indefinite  term.  The  god-like  Achilles,  with 
the  terrible  spear,  smote  Hector  in  the  throat,  above  the  clavicles, 
where  the  neck  starts  from  the  shoulder,  in  order  that  there  might 
be  quick  loss  of  life.  "There  the  point  went  through  the  tender 
neck,"  but  the  Aacpapdyo::  was  not  cut,  in  order  that  the  prostrate 
man  might  answer  the  victor's  cruel  taunts.  It  is  clear,  therefore, 
that  Homer  recognizes,  by  this  term,  the  organ  from  which  the 
voice  issues.  We  may  be  allowed  to  conjecture,  in  the  absence 
of  any  information  to  the  contrary,  that  this  term  Aac^ajxlyoz 
arose  from  the  contemplation  of  the  wind-pipe  as  it  sprouted  from 
the  root  of  the  lungs  of  the  slaughtered  sacrificial  animals,  whose 
entrails  were  examined  by  the  priests  in  their  religious  ceremonies 
for  prophetic  indications.  It  must  have  appeared  to  them  not 
unlike  a  thick  stalk  of  the  vegetable  for  which  the  word,  in  one  of 
its  two  forms,  was  identical,  according  to  the  dictionary.  From 
this  may  have  come  c/)do'jf  and  later  ^-aou^.  This,  however,  is 
entirely  conjectural  on  my  part.'^ 

1  (Littre)  VIII,  p.  607.  ^  i^id.,  IX,  p.  169. 

'  While  the  root  of  the  word  pharynx  is  said  to  be  the  same  as  in  <?fY)w — 
Latin  fero — we  may  imagine  it  is  true,  without  any  proof  to  the  contrary,  that 
the  word  aspharagos  arose  as  here  stated. — Vid.  Cent.  Diet,  and  Greek  Lexicon. 
Luschka  (Der  Schhmdkopf  des  Menschen,  Tubingen,  1S68)  prefers  a  different 
derivation,  but  the  etj'mology  he  refers  to  woukl  presuppose  an  amount  of 
anatomical  knowledge  in  Homer  or  the  jirimitive  Greeks  who  composed  his 
songs,  which  we  may  well  hesitate  to  ascribe  to  them. 


40  PRE-HIPPOCRATIC  MEDICINE  IN  GREECE 

DarembcTg  is  of  the  oj^inion  that  TTonier,  and,  of  course,  by 
Homer  we  mean  the  men  of  his  day,  knew  that  food  and  drink 
passed  down  the  gullet.  He  refers  to  tlie  Iliad  (XXIV,  041,  642), 
but  I  am  not  satisfied  that  /M:jy.aucr^;,  tiie  word  employed,  meant 
the  oesophagus.  It  seems  to  have  been  api)lie(l  almost  as  loosely 
as  the  other  Greek  words  for  throat  (vid.,  XXII,  325). 

We  will  diseuss  later  the  interesting  error  of  the  ancients  in 
regard  to  the  destination  of  liquids  when  swallowed.  It  is  well 
known,  of  course,  that  the  word  trachea  arose  from  the  subsequent 
use  by  Erasistratus  of  that  Greek  adjective,  meaning  "rough," 
in  connection  with  the  artery  (aor/^fHo.  T(>aysia)  to  signify  that 
it  belonged  to  the  same  class  of  structures  as  we  now  know  to 
carry  blood  and  not  air.  The  artery  part  of  the  name  was  dropped 
when  this  error  passed  away  and  the  trachea  remained,  lioayyo' 
was  a  word  also  frequently  applied  to  the  whole  wind-pipe,  but 
later  coming  into  use  for  the  channels  below  the  division  of  the 
trachea. 

Finally,  I  quote  from  another  brochure  of  Daremberg^  the 
derivation  of  another  term  rhinologists  use  every  day: 

Euripides  (Fragm.  1044)  is,  I  believe,  the  first  author  where 
one  meets  with  MoxTrnj — the  nostrils  or  the  nose.  It  seems  also 
that  Sophocles  (Fragm.  581),  and  especially  Aristophanes  (Fragm. 
650),  calls  the  nose  or  the  nostrils  by  the  name  Mu^a,  which  is 
regularlv  applied  to  the  mucus  which  escapes  from  them.  (The 
Knights,  910;  The  Wasps,  1488.) 

Scientific  and  i)hilosophical  records  being  so  defective,  and 
purely  medical  treatises  being  entirely  lost,  if  any  existed  before 
the  Hippocratic  era  in  Greece,  we  cannot  hope  to  glean  much  in 
regard  to  our  subject  from  this  period.  Nevertheless  some  faint 
reflections  may  be  found  in  the  works  of  the  later  writers. 

Early  Greek  Superstition. — Here  is  a  fragment  suggestive  of  the 
character  of  early  (ireek  medicine,  showing  that  it  differed  little 
from  that  of  other  rude  and  uncivilized  races.  The  Dog  and  the 
Serpent  were  alike  sacred  to  .F]scula])ius,  and  on  the  second  one 
of  the  columns,  seen  by  Pausanias  at  Ei)idaurus,  this  record  has 
been  found  engraved  among  others  of  medical  interest,  testifying 
to  the  efficacy  of  the  holy  dogs  kept  at  the  shrines.  A  child  of 
Aegina,  "affected  with  a  tumor  of  th<>  neck,  ap]ilied  to  the  god. 
One  of  the  sacred  dogs  licked  the  affected  part  and  cured  it.'"^ 

Philosophy  has  always  at  all  epochs  of  Medicine  dominated  it. 
Pythagoras  established  four  elements:  Earth,  Fire,  Air,  and  Water 

1  L'Etat  dc  la  Mi'decino  entrc  Homore  et  liippocratc,  Pari.s,  1SG9,  p.  14. 

2Roinac-h:  Revue  Arclieologique,  1884,  II,  p.  129;  1885,  I,  p.  267.  For  a 
most  interesting  aeeount  of  the  Temple  of  Aeseulapius  at  K]n(laurus,  see  a 
paper  by  W.  S.  Coleman,  M.D.,  F.R.C.P.,  St.  Thomas'  Hospital  Reports,  Vol. 
XXVII,  1898,  p.  397. 

For  a  very  readable  aeeount  of  the  cult  at  Epidaurus,  see  The  temples  and 
Rituals  of  Asklepios,  by  Richard  Caton,  M.D.,  etc.,  1900. 


THE  EUSTACHIAN  TUBE  41 

— Empedocles  admits  these,  but  adds  to  them  their  quaHties: 
the  cold  and  hot,  the  wet  and  dry,  which  are  found  in  medicine 
until  the  Renaissance. 

In  Plutarch's  "Morals"^  there  are  to  be  found  some  curious 
chapters  on  the  senses,  and  he  there  quotes  from  many  of  the  old 
Greek  philosophers  who  lived  before  the  time  of  Hippocrates  and 
whose  writings  were  apparently  extant  in  the  time  of  Plutarch  (46 
A.D.).  The  chapters  on  smell  and  taste  are  of  interest  to  us 
here. 

"Alcmaeon  (520  B.C.)  believes  that  the  principal  part  of  the 
soul,  residing  in  the  brain,  draws  to  itself  odors  by  respiration. 
Empedocles  (490  B.C.),  that  scents  insert  themselves  into  the 
breathing  of  the  lung;  for  when  there  is  great  difficulty  in  breath- 
ing, odors  are  not  perceived  by  reason  of  the  sharpness;  and  this 
we  experience  in  those  who  have  the  defluxion  of  Rheum." 

"Alcmaeon  says  that  a  moist  warmth  in  the  tongue,  joined  with 
the  softness  of  it,  gives  difference  of  taste.  Diogenes,-  that  by 
the  softness  and  sponginess  of  the  tongue,  and  because  the  veins 
of  the  body  are  joined  in  it,  tastes  are  diffused  by  the  tongue;  for 
they  are  attracted  from  it  to  that  sense  and  to  the  commanding 
part  of  the  soul,  as  from  a  sponge." 

The  Eustachian  Tube. — Alcmaeon  is  said  to  have  been  the  first 
Greek  anatomist  and  to  have  dissectedthe  eyes  and  ears  of  animals, 
discovering  the  optic  ner\'e  and  the  Eustachian  canal,  thus  antedat- 
ing in  the  latter  discovery  Eustachius  by  many  centuries.  Aristotle 
(Hist.  Animal  I,  IX,  1)  comments  on  a  mistake  of  Alcmaeon  in 
supposing  that  goats  breathed  through  their  ears.  It  is  singular 
that  this  error  should  crop  out  so  late  as  the  seventeenth  century 
A.D.,  but  Tulpius  may  be  found^  asserting,  in  spite  of  Aristotle, 
that  on  account  of  this  anatomical  configuration,  as  described  by 
Alcmaeon,  it  is  possible  in  labored  inspiration  for  air  to  find  this 
auxiliary  passage  to  the  lungs.  Kassel  has  drawn  attention  to  a 
passage  in  a  papyrus  No.  1558  from  the  Egyptian  Museum  dating 
back  1400  years  before  Christ  in  which  it  is  said,  "There  belong 
two  vessels  to  his  left  ear  through  which  the  breath  of  life  goes; 
there  belong  two  vessels  to  his  right  ear  through  which  the  breath 
does."  We  may  conjecture  from  this  that  the  source  of  Alcmaeon's 
knowledge  as  that  of  most  of  the  knowledge  of  his  day  was 
p]gyptian.  Whether  any  of  this  error  may  have  arisen  from 
observations  of  pathological  perforations  of  the  drum  membrane 
is  a  permissible  conjecture  only. 

1  Translation.     Ed.  Goodwin,  1870,  Vol.  Ill,  p.  170  (De  Placitis  Philos.). 

-  I  presume  Plutarch  hero  refers  to  Diogenes  of  Apollonia,  born  in  the  fifth 
century  B.C.,  who  described  the  distribution  of  the  bloodvessels,  which  is  to  be 
found  in  the  fragment  of  his  writings  still  preserved.  Fragm.  Philosoph.  Graec. 
MuUach,  Vol.  I,  p.  254. 

'  Observat.  Med.  Amst.,  1641,  Lib.  I,  Cap.  XXXV. 


42  PRE-HIPPOCRATIC  MEDICINE  IN  GREECE 

Ak'inaeon  explained  hearing  by  the  hollow  bone  behind  the 
ear — "for  all  hollow  things  are  sonorous."     (Plutarch,  1.  c.)^ 

Emj^edocles  discovered  the  labyrinth  of  the  ear  and  explained 
sound  by  the  impress  of  air  upon  it  as  upon  a  drum.  In  one  of 
the  fragments  preserved  from  the  "Carmina  of  Empedocles,"-  we 
read:  "Thus  they  breathe  out  and  in.  Bloodless  tubes  extend 
through  all  the  flesh  throughout  the  whole  body,  and  the  end  of 
these  placed  within  the  nostrils  is  perforated  by  large  ()i)enings 
leading  to  the  cavities  (cerebral?)  so  that  they  may  hold  back 
the  blood  and  open  free  passage  for  the  air  through  the  meatus." 
This  perhaps  would  suffice  to  illustrate  the  confusion  in  regard 
to  anatomy  which  existed  among  the  best  informed  of  those  phil- 
osophers older  than  Hippocrates,  but  I  may  perhaps  be  allowed 
to  add  an  embryological  idea  which  Sprengel  has  found  among 
the  fragments  of  verses  of  Empedocles:  "He  attributed  the  forma- 
tion of  the  abdominal  cavity  and  that  of  the  intestines  to  the  sud- 
den and  rapid  passage  of  water  through  the  body  at  the  moment 
of  its  formation,  and  the  external  openings  of  the  nose  to  a 
current  of  air  which  was  established  from  the  interior  to  the 
exterior." 

Diogenes  of  Apollonia  (500-400  b.c.)  explained  the  superior 
intelligence  of  men  by  supposing  they  breathed  a  purer  air  than 
the  beasts  which  carry  their  noses  near  the  ground.     (Draper.^ 

The  Atomic  Theory. — Democritus  is  said  to  have  been  born  at 
Abdera  in  the  same  year  (460  B.C.)  and  to  have  been  greatly  admired 
by  Hippocrates,  who  reproved  the  countrymen  of  Democritus  for 
having  supposed  him  insane  and  for  sending  for  him  to  cure  him. 
He  is  said  to  have  derived  his  atomic  theory  from  Leucippus  (500 
B.C.).  He  is  quoted  by  Plutarch  (1.  c.)  in  regard  to  the  voice  as 
saying  that  "the  air  is  broken  into  bodies  of  similar  configuration 
and  these  are  rolled  up  and  down  with  the  fragments  of  the  voice." 
This  statement  seems,  of  course,  rather  fantastical  and  we  might 
suspect  Plutarch  had  confused  a  more  intelligible  passage  from 
Democritus  did  we  not  find  in  one  of  the  fragments-'  remaining  to 
us  from  Democritus  an  analogous  statement  as  to  taste,  the  dis- 
tinctions of  which  he  attributed  to  the  different  shapes  of  his 
atoms.  Plutarch  continues :  " The  stoics  say  the  air  is  not  composed 
of  small  fragments,  but  is  a  continued  })ody  and  nowhere  admits 
a  vacuum;  and  l)eing  struck  with  the  lircath,  it  is  infinitely  moved 
in  waves  and  in  right  circles  until  it  fills  that  air  which  invests  it, 
as  Ave  see  in  a  fish  pool  which  we  smite  by  a  falling  stone  cast  upon 
it;  yet  the  air  is  moved  spherically,  the  water  orbicularly.  Anaxa- 
goras  (500  B.C.)  says  a  voice  is  then  formed,  when  upon  a  solid 

1  See  also  Kuehn:  Opusoula  Minora,  I,  p.  09. 

^Fragm.  Philosoph.  Grace,  MuUacli,  1875,  2(1  Vol.  I,  34)3  ff. 

=>  Ibid.,  Vol.  II,  p.  362. 


HIPPOCRATES  AS  A  SPECIALIST  43 

air  the  breath  is  incident,  which  being  repercussed  is  carried  to  the 
ears;  after  the  same  manner  the  echo  is  produced."  Out  of  much 
which  is  to  us  mere  jargon,  but  which  to  them  was  perhaps  full  of 
meaning,  it  may  be  seen  that  w^e  may  occasionally  extract  passages 
which  need  little  altering  to  conform  with  modern  doctrine.^ 


THE  HIPPOCRATIC  TREATISES. 

So  completely  have  the  records  of  Greek  medicine  before  the 
time  of  Hippocrates  perished,  that  he  seems  himself  to  have  created 
it.  It  seems  to  have  sprung  from  him  and  his  associates,  like 
Athene  from  the  head  of  Zeus,  or  like  the  sudden  growth  of  the 
infant  Apollo  after  tasting  of  the  ambrosial  cup  from  the  hand  of 
Themis,  to  have  started  at  once  into  the  full  life  of  a  A^gorous  and 
fruitful  manhood.  We  mav  be  sure,  however,  from  the  cold  analvsis 
of  historical  experience  and  of  philosophical  logic  that  there  must 
have  been  a  long  previous  condition  of  growth  and  develop- 
ment, which  cannot  be  traced  in  the  scantv  remnants  of  historv 
left  us. 

Hippocrates  as  a  Speciahst. — On  the  authority  of  Celsus-  we 
must  accept  Hippocrates  as  really  the  first  medical  specialist  in  our 
civilization,  for  he  was  the  first  to  separate  medicine  from  other 
sciences  and  devote  himself  exclusively  to  that  branch  of  knowledge, 
for  which,  no  doubt,  as  we  may  judge  from  reading  Plato,  he  was 
regarded  by  other  philosophers  as  lamentably  narrow  and  one- 
sided. Reasoning  from  experiences  of  later  ages,  we  may  imagine 
that  after  a  little  time  some  philosophers,  who  thirsted  after  the 
reputation  of  progressiveness,  acknowledged  that  this  specialization 
might  possibly  be  excusable,  provided  the  heretic  had  first  spent 
all  the  productive  years  of  his  youth  in  the  pursuit  of  inquiry  into 
the  nature  of  the  gods  and  the  occult  properties  of  the  four  cardinal 
elements,  fire,  earth,  air,  and  water.  I  cannot  forbear  giving  here 
Celsus'  explanation  of  how  it  happened  that  philosophers  took  up 
the  study  of  medicine  at  all,  since  it  is  somewhat  amusing.  He 
intimates  that  the  old  philosophers  spent  so  much  of  their  time 
in  sedentary  contemplation  and  nocturnal  vigils  that  they  fell 


^  It  is  absolutely  necessary  for  any  one  desiring  an  intelligent  knowledge 
of  the  medical  theories  in  the  writings  of  Hippocrates  and  of  all  subsequent 
medical  writers,  that  he  should  acquaint  himself  thoroughly  with  the  material 
and  psychic  philosophy  of  the  ancients.  A  very  good  resume  of  the  subject  so 
far  as  it  applies  to  medical  doctrines  may  be  found  in  the  Preliminary  Discourses 
attached  to  Adams'  Sydenham  edition  of  The  Genuine  Works  of  Hippocrates, 
while  Draper  in  his  Intellectual  Development  of  Europe  gives  a  somewhat 
biased  review  of  Greek  philosophy  in  its  broader  ramifications.  In  the  Pro- 
emium  of  Celsus,  however,  will  be  found  the  most  succinct  and  the  clearest 
account  of  Medical  Schools  among  the  ancients. 

2  De  Medicina,  Lib.  I,  Praefatio. 


44  THE  IlIPPOCRATIC  TREATISES 

sick,  and  were  forced  to  resort  to  the  study  of  medicine  to  cure 
themselves.' 

The  ci\ihzati()n  of  the  ("haldean  and  the  Parsee,  of  the  Egyptian, 
and  even  of  the  Ilinchi  is  strange  and  incomprehensible  to  us, 
but  we  instinctively  feel  that  the  Isles  of  Greece,  that  Cos,  over 
opposite  Abdera  is  a  familiar  land,  and  that  there  we  will  find  a 
mental  activity  into  which  we  are  al)le  to  enter.  When  we  read  in 
Xenophon's  Anabasis  (III,  119)  that  the  soldiers  cried  out  when 
their  comrade  sneezed,  "Zsu  acoaov]"  "God  save  you,"  immediately 
comes  to  our  mind  the  Frenchman's  ejaculation  "Dieu  vous 
benisse,"  and  the  Germans'  hail,  "Gesundheit."-  Turn  to  Hip- 
pocrates' account  of  the  case  "in  Thasus,  the  wife  of  Dealces  who 
was  lodged  on  the  plain"^  and  read  there  his  account  of  a  death 
from  fever  with  cerebral  symptoms.  No  such  vivid  impression 
is  left  on  the  mind  by  any  other  portrayal  of  the  fatal  march  of  a 
mortal  disorder  until  we  find  Shakespeare  describing  in  Dame 
Quickly's  patois  the  death  of  Falstaff,  who  was  "so  shak'd  of  a 
burning  quotidian  tertian  that  it  is  most  lamentable  to  behold," 
and  how  "at  the  turning  o'  the  tide"  she  saw  him  "fumble  with 
the  sheets  and  play  with  flowers  and  smile  on  his  fingers  end,"  and 
noted  that  "his  nose  was  sharp  as  a  pen,"  how  "a'  babbled  of 
green  fields,"  and  cried  out,  "God,  God,  God,  three  or  four  times," 
and  "his  feet  were  as  cold  as  anv  stone."  The  wife  of  Dealces 
fumbled  with  the  bed  clothes  and  picked  at  the  hairs  on  them  and 
laughed  and  there  was  much  talk  and  again  she  was  silent.  Adams 
(1.  c.  p.  19())  supposed  Shakespeare  to  have  derived  his  description 
second  hand  from  the  celebrated  passage  in  Hippocrates^  as  to 
the  facies  of  death,  but  it  seems  to  me  that  it  bears  a  much  closer 
resemblance  to  the  description  I  have  alluded  to.  I  do  not  believe 
Shakespeare  ever  had  any  knowledge  of  either  of  these  passages 
in  the  Hippocratic  writings,  either  first  hand  or  second  hand.  We 
are  struck  by  the  resemblance  of  the  impressions  made  on  our 

'  Therefore,  after  those  of  wliom  I  liave  spoken,  no  distinguished  men  prac- 
tised medicine  until,  by  the  more  diligent  study  of  letters,  education  began  to 
be  jiursued  wliich,  although  indeed  necessary  of  all  things  for  the  mind,  is 
inimical  to  tlu;  bod.y.  Some  have  it  that  the  science  of  medicine  first  began 
because  the  cure  of  diseases  and  the  contemplation  of  nature  were  pursued 
by  the  same  authors.  This,  moreover,  was  especially  necessary  to  those  who 
injured  the  strength  of  their  bodies  by  sedentary  thought  and  by  late  hours. 
Therefore,  we  believe  that  many  of  those  who  were  (>xpert  in  the  knowledge 
of  things  suffered  in  this  way.  ^J'he  most  distingui.shed  of  these  were  Pythagoras, 
Empedocles,  and  Democritus.  T\w  latter  as  some  believe  had  llipijocrat.es 
of  Cos  for  a  disciple,  the  hrst  and  indeed  the  one  of  all  most  worthy  to  be  held 
in  memory,  for  he  separated  this  science  from  other  pursuits,  a  man  distinguished 
in  art  and  in  natural  attainments. 

-  This  ancient  custom,  however,  is  older  than  the  Greek  civiHzation. 

^  Kj)idemics  III,  Sec.  17,  case  XV.     (Adams)  I,  p.  349. 

^Prognostics  2  (Adams)  I,  p.  285.  Her(\'ifter,  in  the  references  to  Hippo- 
crates' works,  English  terms  refer  to  Sydenham  (Aflams)  edition,  (N.  Y.:  Wm. 
Wood  &  Co.,  1891,  2  vols,  in  one);  French  terms,  the  Littre  edition;  and  Latin 
terms  to  the  Kiihn  edition. 


THE  ERA  OF  HIPPOCRATES  45 

minds  by  the  words  of  two  masters  in  the  description  of  similar 
objective  phenomena.  It  is  the  stroke  of  the  master  artist,  the 
touch  of  immortal  genius  which  sprang  as  frequently  from  the 
soil  of  Greece  in  its  Golden  Age  as  it  did  from  that  of  Britain  at 
the  zenith  of  her  literary  glory.  Such  objectivity  is  not  to  be 
found  in  the  Orientals'  dream  of  life.  Do  we  find  here  an  explana- 
tion, or  part  of  an  explanation,  of  why  the  civilization  of  the 
Orient,  of  the  Ganges,  and  of  the  Nile  has  stood  still  for  3000  years 
and  cannot  now  be  aroused  from  the  slumber  of  so  manv  centuries? 


At  least  we  can  comprehend  somewhat  from  this  objectivity  how 
the  virile  fructifying  aggressive  mind  of  the  Ancient  Greek  furnished 
a  soil  for  the  quick  luxuriant  growth  of  seeds  from  a  dying  civiliza- 
tion, dying  even  then  with  its  youth  stretching  back  into  the 
inscrutable  past  of  prehistoric  times. 

The  Era  of  Hippocrates. — It  must  be  borne  in  mind  that  Hip- 
pocrates lived  in  that  glorious  time  of  Greek  civilization  and  culture, 
the  golden  age  of  Pericles,  that  his  life  overlapped  that  of  Phidias 
and  Praxiteles,  of  Anaxagoras,  Socrates  and  Democritus,  of 
.Eschylus,  Euripides,  Sophocles  and  Aristophanes,  of  Herodotus, 
Thucydides  and  Xenophon,  of  Plato,  Aristotle,  and  Demosthenes. 
Never  since,  in  the  history  of  the  world,  have  there  existed  in  the 
span  of  one  man's  life  so  many  men  whose  fame  still  shines  in 
mortal  records  and  whose  words  still  influence  the  thoughts  of 
men.  Such  a  throng  was  not  to  be  gathered  from  all  the  broad 
empire  of  Augustus,  nor  to  be  found  in  the  brilliant  court  of  the 
Grand  Monarque,  nor  among  those  who  flourished  in  the  days  of 
England's  Mrgin  Queen.  None  can  say  that  the  great  name  of 
Hippocrates  stands  less  illustrious  on  the  role  of  medical  science 
than  does  that  of  Socrates  in  philosophy,  of  Phidias  in  sculpture, 
of  Demosthenes  in  oratory,  of  Thucydides  in  history,  or  of  Aristotle 
in  science.^  It  is  the  evidence  of  the  knowledge  of  the  upper  air 
passages  and  their  diseases  possessed  by  this  great  primeval  figure 
in  medicine  with  which  we  are  now  concerned.  Among  the  large 
number  of  writings  ascribed  to  Hippocrates,  there  are  only  a  few 
which  have  been  acknowledged  by  all  authorities  to  have  been 
really  written  by  him.  Some  have  been  pro\'ed,  many  have  been 
surmised,  to  have  been  written  by  his  predecessors  and  successors. 
It  seems  probable  that  some  were  written  by  others  during  his 
lifetime  who  had  the  benefit  of  his  guidance  and  of  his  instruction. 
However  this  may  be,  it  is  not  my  aim  to  enter  into  a  general  dis- 
cussion of  such  matters,  but  rather  to  bring  into  prominence  tliost-. 
gleams  of  light  thrown  upon  our  subject  which  have  come  to  us 
across  twenty-five  centuries.  A  reference  to  the  editions  of  Adams 
and  of  Littre  and  to  the  works  of  Galen  will  enlighten  the  reader 
as  to  the  books  which  are  accredited  to  Hippocrates  himself  and 

1  Littr6's  Introduction  to  Ocuvres  Completes  d'Hippocrate. 


46  THE  IIIPPOCRATIC   TREATISES 

as  to  those  which  are  supposed  to  have  been  written  by  others 
of  his  time  or  school.  Some  of  the  passages  in  the  writings  of  these 
.Esclepiadoe  seem  ridiculous  to  us,  but  we  should  keep  constantly 
in  mind  the  charity  which  our  successors  in  their  histories  will 
have  to  extend  to  the  productions  of  our  own  times.  Indeed,  in 
looking  over  the  various  commentaries  on  Hippocrates  from  Galen's 
time  to  our  own,  it  is  curious  and  not  a  little  amusing  to  observe 
how  careful  each  critic  is  to  point  otit  the  errors  Hippocrates 
committed  in  not  being  in  accord  with  the  doctrines  of  the  critic's 
own  time,  which  are  now  as  obsolete  as  those  of  Hippocrates. 
So  little  does  Hippocrates  have  to  say  of  the  cure  of  diseases  that 
Asclepiades,  an  early  type  of  the  genus  charlatan,  subsequently 
ridiculed  his  system  by  saying  it  was  the  contemplation  of  death. 
It  is  perfectly  evident  that  he  recognized  the  futility  of  drugs  as 
ctirative  agents,  and  all  his  works,  especially  those  which  are 
supposed  to  be  genuine,  testify  to  the  persistence  with  which  he 
studied  the  symptomatology  rather  than  the  pharmacology  of 
disease. 

Innumerable  facts  have  been  discovered  since  these  early  times, 
and  the  wonder  chiefly  is  that  they  should  have  then  been  able  to 
reason  as  acutely  as  they  did  from  the  little  acttial  knowledge 
they  had  of  normal  anatomy  or  of  pathological  processes.  ^Ye 
have  seen  from  the  few  extracts  I  have  been  able  to  gather  how 
primitive  knowledge  of  the  anatomy  and  physiology  of  the  upper 
air  passages  was.  In  the  Hippocratic  treatises  themselves  we  find 
it  little  more  advanced. 

In  fact,  until  the  writings  of  Galen,  the  knowledge  of  anatomy 
seems  to  have  been  ahuost  nil  from  a  modern  standpoint. 

The  Destination  of  Fluids. — "Drink  through  the  pharynx  and 
oesophagus.  Larynx  to  the  lungs  and  trachea.  From  these  to 
the  top  of  the  bladder."  This  is  the  literal  translation  of  the 
Greek  text  as  given  in  Kiihn's  edition,  but  Kiihn  himself  translates 
it  "Potus  per  fauces  et  gulam,  arteri;e  stimmum,  quod  larynx 
dicitur,  in  ptilmonem  et  arteriam  ex  quibus  in  summam  vesicam." 
This  latter  passage  occurs  in  the  book  on  the  Nature  of  the  Bones 
(i),  which  is  apparently  a  collection  of  notes.  In  the  fragment  of 
the  book  on  "  Anatomy"  we  find  it  stated  that  the  bronchi  terminate 
at  the  top  of  the  lungs,  being  composed  of  curved  rings.  Then 
follows  a  description  of  the  lungs  and  of  other  organs  detailed  in 
such  a  manner  that  no  room  is  left  for  the  supposition  that  the 
writer  had  any  idea  that  fluids  passed  through  the  lungs  to  the 
bladder.  Again,  elsewhere, ^  we  find,  "If  any  one  will  give  water 
tinctured  with  a  blue  color  or  with  vermilion  to  a  thirsty  l)east 
to  drink,  preferably  to  a  swine,  for  this  beast  is  not  fastidious  but 

'  De  Corde  Liber.  Magni  Hippocratis  Opera  Omnia,  edit.  Kuhn.  Lipsiae, 
182.5-27,  I,  p.  485. 


THE  DESTINATION  OF  FLUIDS  47 

dirty,  and  will  then  cut  the  beast's  throat  after  the  drinking,  he 
will  find  it  colored  with  the  fluid."  Nevertheless,  he  says  the 
greater  part  of  it  goes  to  the  stomach.  At  the  end  of  the  Fourth 
Book  on  Diseases  the  author  distinctly  combats  the  idea  that 
drink  passes  through  the  larynx.  It  is  evident,  therefore,  from  these 
quotations  that  no  one  man,  but  several,  wrote  the  so-called 
Hippocratic  treatises.  History  tells  of  the  great  rewards  offered 
by  the  Ptolemies  for  manuscripts  of  well-known  authors  for  their 
great  library,  and  nothing  seems  more  certain  than  that  enterpris- 
ing, and  of  course  highly-respectable  "rare-book"  dealers,  found  it 
more  convenient  to  write  than  to  find  hitherto  unknown  treatises 
of  Hippocrates.  The  author  of  the  Fourth  Book  on  Diseases  says, 
referring  to  the  epiglottis,  that  the  presence  of  a  process  in  the 
form  of  an  ivy  leaf  prevents  liquid  from  entering  the  larynx  and 
keeps  it  in  the  pharynx.  He  declared  that  the  sounds  emitted  on 
expiration  were  multiplied  by  the  resonance  of  the  head.  The 
tongue  articulates  as  the  air  is  driven  out  striking  against  the 
palate  and  the  teeth.  "All  of  which  shows  that  it  is  the  air  which 
makes  the  noise."  In  the  book  on  the  Flesh  (19)  it  is  recognized 
that  severance  of  the  larynx  stops  the  voice,  which  is  regained 
when  it  is  reunited. 

On  the  subject  of  the  destination  of  liquids  when  swallowed, 
there  is  a  very  curious  chapter  among  Plutarch's  "Symposiacs" 
(Book  VII).  When  a  line  from  the  poet  Alcseus  (611,  580  B.C.) 
was  quoted,  "Now  drench  they  lungs  Avith  wine,  the  dog  appears"^ 
(Dog  Star),  Nicias  of  Nicopolis,  a  physician,  is  made  to  say  that 
Plato  should  be  reproved  for  the  passage  in  the  Timsesus-  where  he 
adopts  the  same  error.  He  enters  into  an  argument  in  refutation 
of  the  idea  that  the  drink  passes  into  the  lungs,  and  he  instances 
the  epiglottis  as  an  apparatus  for  preventing  it.  In  the  discussion 
which  followed  Protogenes,  the  grammarian,  claimed  that  Homer 
first  spoke  of  the  stomach  as  the  receptacle  of  the  food,  and  of  the 
breath  and  windpipe  as  the  instruments  of  the  voice,  but  the  dis- 
cussion on  this  passage  in  Homer  hinged  upon  the  meaning  of  the 
word  4>o-y'J^,  which  we  have  seen  had  a  very  indefinite  meaning. 
Florus  quoted  many  poets,  among  them  Euripides,  who  affirm 
with  Plato  that  the  drink  passes  into  the  lungs,  and  the  conclusion 
of  Plutarch's  Symposium  seemed  to  be  that  Plato  was  right. 
Florus  asserts  that  not  only  Hippocrates,  but  his  pu])il,  Dioxip])us, 
(390  B.C.?)  and  Philistion,  a  very  ancient  physician  of  Locri,  had 

iVid.  Gaisford:  Poet.     Min.  Giaec,  Vol.  Ill,  p.  321,  XVIII. 

^  The  passage  referred  to  reads  "the  hing  is  a  soft  and  bloodless  organ,  and, 
moreover,  is  full  of  pores  internally,  like  a  sponge,  in  order  that  receiving  air 
and  drink  it  may  refresh  the  heart,  quiet  it  and  cool  the  heat  which  burns  it. 
This  is  the  reason  why  the  channels  of  the  trachea  are  directed  toward  the 
lung,  and  the  lung  is  placed  near  the  heart.  A  few  lines  farther  on  it  is  evident, 
however,  that  Plato  recognized  that  some  of  the  licjuids  at  least  go  to  the 
stomach,  or  rather  "the  region  between  the  diaplu-agm  and  the  navel." 


48  THE  niPPOCRATIC  TREATISES 

no  other  thought.  Dioxippiis  supi)osed  that  the  epiglottis  served 
to  di\ide  the  food  and  drink  into  the  coarser  parts  which  passed 
into  the  stomach  and  the  finer  parts  which  passed  into  the  hnigs. 
Aristotle'  did  not  share  this  error  at  all,  but  distinctly  states  that 
the  larynx  is  only  for  the  passage  of  the  air  and  the  voice.  From 
a  passage  in  this  symposium  Sprengel  seems  to  draw  the  conclusion 
that  Erasistratus  taught  that  the  drink  does  not  pass  into  the 
lungs.  Now,  Plutarch's  writings  are  of  a  date  in  the  first  century 
of  the  Christian  era,  500  years  after  the  time  of  Hippocrates  and 
400  years  after  the  time  of  Erasistratus.  One  hundred  years  after 
Plutarch  we  find  even  Galen  in  a  modified  form  entertaining  this 
idea.  lie  says,  in  reference  to  it:  "If  Plato  supposed  that  we 
take  all  our  drink  into  our  lungs,  it  is  proper  to  remark  that  he 
was  ignorant  of  a  very  evident  matter.  If  he  supposed,  however, 
some  part  of  the  drink  passing  through  the  trachea  is  carried  to 
the  lungs,  he  announces  a  thing  possible  and  like  other  matters 
concerning  which  physicians  and  philosophers  may  disagree  among 
themselves."  He  then  proceeds  to  state  that  it  is  quite  possible 
for  a  small  amount  of  fluid  to  steal  down  the  sides  of  the  air  tubes 
without  producing  irritation  sufficient  to  cause  a  cough. 

We  may,  since  we  have  already  digressed  somewhat,  add  here 
another  mention  of  Hippocrates  by  Plutarch. ^  He  compliments 
him  as  a  man  of  wonderful  skill  in  physic  and  fit  to  be  imitated 
by  the  greatest  philosoi)hers,  especially  as  to  his  ingenuousness, 
for  "he  confessed  publicly  that  he  had  mistaken  the  nature  of  the 
sutures  cf  the  skull,^  and  has  left  an  acknowledgment  under  his 
own  hand ;  for  he  thought  it  very  unworthy  a  man  of  his  profession 
not  to  discover  where  he  was  in  the  wrong  seeing  that  others  might 
sufter  and  err  by  his  authority."  Plutarch's  comment  on  this  is 
quite  as  ap])licable  today  as  in  his  own  time.  "And  indeed  it 
had  been  very  unreasonable,  if  he  whose  business  and  concern  it 
was  to  save  others  and  set  them  right  should  not  have  had  the 
courage  to  cure  himself  and  to  discover  his  own  weakness  and  the 
imperfections  in  his  own  faculty."  Quint ilian  echoes  Plutarch's 
eulogium.' 

The  Origin  of  Catarrhs. — When  we  realize  that  the  ani'ients, 
IIipj)ocrates,  Galen,  and  their  followers,  knew  nothing  of  the 
muciparous  glands,  and  of  course  nothing  of  the  function  of  these 
microscopic  structures,  it  is  easy  to  understand  the  absolute  mental 
necessity  for  them  to  find  some  ex])lanati()n  of  the  origin  of  the 
secretions   which   bathe   not   only   the   respiratory   tract,   but   the 

'  On  the  Parts  and  Gait  of  Animals,  III,  111,  4. 

2  Man's  Progress  in  \'irtue. 

3  Vid.  Hippocrates:  Epid.  V,  §  27— cf.  Dc  Vuln.  Cap.  §  12. 

■*  Celsus,  from  whom  probably  Plutarch  and  (^iiinf  ilian  drew  their  informa- 
tion, remarks  in  regard  to  Hippocrates'  superiority  in  this  resjx'ct  over  lesser 
men.  Nam  levia  ingenia,  quia  nihil  habent,  nihil  sibi  detrahunt.  Lib.  VIII, 
Cap.  IV. 


THE  ORIGIN  OF  CATARRHS  49 

gastro-intestinal  mucous  membranes  as  well.  As  for  the  moisture 
of  the  lungs,  it  is  natural  that  they  should  look  for  some  explanation 
in  the  liquids  swallowed.  This  lack  of  knowledge,  as  well  as  a 
mistaken  anatomical  observation,  led  them  into  another  error 
which  persisted  still  longer.  The  cribriform  plate  of  the  ethmoid 
bone  (the  sieve-like  bone)  at  the  top  of  the  respiratory  tract  was 
usually  seen  only  in  the  dried  specimen  by  the  ancients  unfamiliar 
with  dissection  of  the  human  body.  The  idea  arose  that  the  humors 
were  distilled  in  the  gland-like  contents  of  the  cerebral  cavities 
and  sifted  through  the  cullender  plate  of  the  ethmoid  to  parts 
below.  If  we  can  find  no  trace  of  this  idea  in  Hindu  or  Egyptian 
medicine,  Herodotus^  supplies  us  with  indubitable  evidence  that 
it  existed  among  the  Libyans.  He  says:  "The  Libyans,  when 
their  children  come  to  the  age  of  four  years,  burn  the  veins  at  the 
top  of  their  heads.  Others  burn  the  veins  about  the  temples. 
This  they  do  to  prevent  them  from  being  plagued  in  their  after 
lives  by  a  flow  of  rheum  from  the  head  and  such  they  declare  is 
the  reason  they  are  so  much  more  healthy  than  other  men.  Li  all 
this  I  only  repeat  what  is  said  by  the  Libyans  themselves."  This 
burning,  as  we  shall  have  occasion  hereafter  to  note,  was  the 
sovereign  Arabian  cure  for  all  diseases. 

This  idea  of  the  cerebral  origin  of  catarrhs  once  fixed  in  the 
conception  of  medical  men  was  not  detected  as  an  error  even  by 
Galen  himself,  whose  anatomical  knowledge  was  so  extensive.^ 
They  supposed  that  the  airs  and  vapors,  as  they  called  them,  were 
inspired  through  the  cribiform  plate  by  the  brain  acting  like  a 
live  sponge,  drawing  up  into  itself  not  only  the  moisture  but  the 
air  of  the  nasal  cavities  and  then  redistilling  them.  Hippocrates 
says  olfaction  takes  places  through  the  cribriform  plate.  The 
latter  he  describes  as  being  made  of  cartilage,  soft  like  a  sponge, 
and  is  neither  flesh  nor  bone.^  So  entirely  had  this  conception  of 
the  anatomy  and  physiology  of  the  cribriform  plate  taken  possession 
not  only  of  the  medical  mind,  but  so  completely  had  it  passed  into 
the  popular  mind,  that  it  was  supposed  that  the  mental  processes 
were  sluggish  in  those  in  whom  the  faulty  excretion  led  to  a  clogging 
of  the  brain  with  mucus.  Hence,  we  find  in  Greek  that  not  only 
Coryza  stands  for  a  cold  in  the  head,  but  it  was  the  name  applied 
to  a  fool,  a  driveler.  Still  more  was  this  evident  in  the  Latin 
tongue.  "Emunctse  naris"  refers  to  the  mental  acuteness  of  the 
individual  because  he  was  supposed  to  keep  his  nostrils,  the  cloaca 
of  the  brain,  well  cleaned  out.    This  is  found  chiefly  in  the  satirists. 

"Hinc  omnis  pendet  Lucilius,  hosce  secutus 
Mutatis  tantiun  pedibus  numerisque,  facetus, 
EmunctxB  naris,  dui-us  componere  versus." 

Horatii  Satira,  IV,  6. 

1  Liber  IV,  Cap.  187. 

2  Vid.  Galen:  De  Instrumento  Odoratus.     Cap.  IV  (Kuhii),  II,  p.  867. 
•^  Des  Chairs  (Littre),  VIII,  p.  605. 

4 


50  THE  HIPPOCRATIC   TREATISES 

"Obesae  Xaris,"  fatty  or  obstructed  nose,  in  distinction  to 
"emiincti?  naris,"  referred  to  mental  dulness.  ]\Jany  similar 
passages  may  be  found  in  ^Martial.  Hippocrates  believed  that  in 
order  to  smell  well  the  nose  must  be  dry,  and  probably  this  arose 
from  the  observation  of  obtunded  olfaction  during  a  cold.  He 
supposed  that  the  vaporous  parts  of  the  inspired  air  escaped 
through  the  sutures  of  the  skull. 

Hence  we  may  understand  why  Hippocrates  looked  uj)on  the 
brain,  which  he  described  as  a  gland,  as  the  origin  of  all  catarrhal 
troubles,  naming  seven,  of  the  eyes,^  of  the  nose,  of  the  ears,  of 
the  stomach,  of  the  throat  and  lungs,  of  the  spinal  cord,  and  of 
the  hips.  The  acrid  humors  were  distilled  to  these  parts  by  various 
routes — to  the  respiratory  and  digestive  tracts  through  the  cribri- 
form plate — but  all  starting  from  the  brain. 

Coryza. — In  his  book  on  "Ancient  JNIedicine,"  where  he  protests 
against  the  entertainment  of  hypotheses  as  to  etiology,  Hippocrates 
describes  the  symptoms  of  a  coryza.  "This  discharge  is  much  more 
acrid  than  that  which  is  usually  found  in  and  runs  from  the  nostrils 
daily;  and  it  occasions  swellings  of  the  nose  and  it  inflames,  being 
of  a  hot  and  extremely  ardent  nature,  as  you  many  know  if  you 
apply  your  hand  to  the  place;  and  if  the  disease  remains  long,  the 
part  becomes  ulcerated,  although  destitute  of  flesh,  and  hard,  and 
the  heat  in  the  nose  ceases,  not  when  the  defluxion  takes  place, 
and  the  inflammation  is  present,  but  when  the  running  becomes 
thicker  and  less  acrid  and  more  mixed  with  the  former  secretion; 
then  it  is  that  the  heat  ceases."  One  of  the  Aphorisms  (H,  40) 
reminds  us  that  catarrhs  and  coryzas  are  not  severe  in  old  people. 
It  is  clear  from  a  passage  in  the  "Airs,  Waters,  and  Places"  that 
Hippocrates  believed  that  not  only  do  stomach  catarrhs  have 
their  origin  in  the  head,  but  that  nasal  catarrh  produces  gastric 
symptoms.  "Their  bellies  are  subject  to  frequent  disorders,  owing 
to  the  phlegm  running  down  from  the  head."  Another  modern 
idea  we  are  reminded  of  in  the  relation  of  a  case"^  of  habitual  catarrh 
which  was  cured  in  three  days  by  coitus. 

Acute  Throat  Inflammations. — Cynanche,  which  English  trans- 
lators usually  render  as  quinzy,  is  a  term  Hippocrates  applied  to 
nearly  all  the  acute  inflammations  of  the  throat.  Littre  (V,  p.  579) 
discusses  the  cjuestion  as  to  whether  Hippocrates  was  familiar 
with  diphtheria.  Croup,  Littre  calls  it.  It  is  doubtful  whether 
the  cases  are  sufficiently  difl'erentiated  in  the  Hippocratic  writings 
to  make  them  intelligible  to  modern  readers.  Even  in  the  time 
of  Littre's  edition  (1<S4(3)  they  would  seem  more  intelligible  than 
in  these  bacteriological  days.  They  were  of  a  ^•ery  severe  type, 
apparently,  whatever  the  nature  of  them.     We  may  conjecture 

1  Des  Glandes,  VIII,  p.  565. 

2  Des  Epid6mies:  V,  72,  and  VII,  69;  (Littr6)  V,  p.  247,  433. 


INTUBATION  51 

that  the  peciiHar  and  striking  features  of  Ludwig's  Angina  or 
erysipelatous  pharyngitis  and  laryngitis  arrested  Hippocrates' 
attention  and  caused  him  to  record  the  case^  of  "the  woman 
affected  with  quinzy  who  lodged  in  the  house  of  x\riston."  Profound 
constitutional  symptoms,  severe  external  swellings,  and  evidently 
internal  stenosis,  causing  dyspnea  and  the  return  of  fluids  by  the 
nose,  rapidh'  brought  tlie  case  to  a  fatal  termination.  The  etiology 
of  cynanche  was  supposed  by  Hippocrates  to  be  the  coagulation 
of  the  blood  in  the  vessels  of  the  neck.  One  cannot  imagine  what 
sort  of  an  angina  could  be  the  cause  of  opisthotonos-  lasting  forty 
days  and  getting  well.  One  has  only  to  refer  to  "Diseases  II," 
26,  27,  28,  29,  30,  31,  32,^  to  perceive  how  severe  was  the  type  of 
throat  inflammation  with  which  the  Hippocratic  writers  were 
familiar  and  yet  how  impossible  it  is  from  the  description  to  more 
than  guess  at  the  class  we  would  now  put  them  in ;  as,  for  instance, 
No.  26  seems  to  have  been  diphtheria,  while  accounts  of  the  others 
indicate,  some  of  them  a  milder  type  of  disease,  and  some  ending 
fatally,  but  apparently  not  diphtheria.  In  the  "Coan  Prognostics" 
is  a  paragraph  (II,  14)^  which  deals  entirely  with  the  prognostics 
of  acute  throat  inflammations,  but  it  is  of  little  modern  interest. 
In  the  "Aphorisms"  (IV,  34,  35)^  Hippocrates  declares  that  "if  a 
person  laboring  under  a  fever,  without  any  swelling  of  the  fauces, 
be  seized  with  a  sense  of  suft'ocation  suddenly,  it  is  a  mortal  symp- 
tom." ^Moreover,  "if,  in  a  person  affected  with  a  fever,  the  neck 
become  suddenly  distorted  and  he  cannot  swallow,  except  with 
great  difficulty,  although  no  swelling  be  present,  it  is  a  mortal 
symptom."  Antitoxin,  tracheotom}',  and  intubation  have  of  late 
years  somewhat  impaired  the  force  of  this  prognosis,  but  we  still 
recognize  the  gravity  of  the  condition. 

Intubation. — Since  the  following  passage  contains  an  indication 
that  the  idea  at  least  of  intubation  existed  in  Hippocratic  times, 
and  because  also  it  is  a  striking  bit  of  objective  description,  I  will 
translate  it  as  literally  as  possible  from  Kiihn's  text  (Vol.  II,  p.  300) : 

''Cynanche. — From  cynanche,  so-called,  a  man  chokes,  and  it 
seems  to  be  especially  in  the  phar^iix,  and  he  is  unable  to  swallow 
his  spittle  or  anything  else,  and  his  eyes  are  affected  and  start 
forth  as  in  those  strangling,  and  he  stares  with  them  straight 
ahead,  and  he  is  not  able  to  turn  them,  and  he  hiccups  and  starts 
suddenly  up,  and  the  countenance  and  the  pharynx  are  burning, 
and  even  the  neck.  To  those  looking  on  there  seems  nothing  the 
matter.  He  sees  and  hears  dully,  and  from  the  dyspnea  he  knows 
not  what  he  says,  nor  hears,  nor  does,  but  lies  there  with  open 

1  Des  Epidemies,  III,  Case  VII;  (Littiv)  II,  p.  328. 
-  Des  Affections  Internes,  53;   (Littre)  VII,  p.  301. 
3  Des  Maladies,  VII,  p.  41-51. 
•'  Prenotions  Coaciues,  V,  p.  641. 
5  (Adams)  II,  p.  224-225. 


52  THE  HIPPOCRATIC  TREATISES 

mouth  drooling  and  acting  thus.  He  dies  on  the  fifth  or  the  seventh 
or  the  ninth  day. 

"  Paraci/nanche. — When  some  of  tliese  symptoms  are  absent,  it 
appears  the  disease  is  not  so  severe  and  they  call  it  paracynanche. 
It  is  necessary  to  bleed,  especially  from  the  vein  beneath  the 
ni])ple  of  the  breast,  for  this  naturally  follows  from  the  hot  breath, 
pneuma,^  of  the  lung,  and  it  is  necessary  to  purge  by  drugs  or  move 
the  bowels  by  enemata,  and  to  j^^iss  tubes  into  the  pharynx  along 
the  jaws,  so  that  the  breath  may  be  drawn  into  the  lungs,  and  to 
make  them  as  ciuickly  as  possible  to  spit  and  thin  the  lungs  (clear 
them  out?)  and  to  fumigate  with  Cicilian  hyssop,  and  with  sulphur, 
and  with  bitumen,  and  to  breathe  these  in  through  the  tubes  and 
through  the  nostrils  so  that  the  phlegm  may  be  cleared  out,  and 
the  ])harynx  and  the  tongue  may  be  cleaned  in  those  having  phlegm, 
and  the  veins  under  the  tongue  should  be  cut;  and  blood  should 
be  drawn  from  the  elbows  if  the  strength  is  sufficient.  Abstention 
from  wine  should  be  enjoined  and  thin  barley  water  should  be 
taken.  After  the  disease  has  subsided  and  the  appetite  returns, 
purging  with  fresh  elaterium  should  be  employed  so  that  he  may 
not  fall  into  another  illness."  The  appearance  of  an  external 
rash  in  all  these  cases  of  severe,  possibly  scarlatinal  and  diphtheritic 
pharyngitis  and  laryngitis,  was  thought  by  Hii)pocrates  and  Galen, 
and  reasserted  by  Avicenna,  to  be  a  good  sign. 

In  "Diseases  II,"  30  and  31,-  he  recommends  hot  fomentations 
for  what  is  apparently  peritonsillitis,  and  scarification  of  the  tonsils, 
but  this  latter  not  with  sufficient  clearness  to  make  us  sure  of  the 
recommendation.  He  also  speaks  of  treating  external  fistulse, 
resulting  from  this  affection,  with  the  cautery.  Evidently  we  have 
here  a  confusion  of  diseases  according  to  modern  classification. 

Uvulotomy  and  Evulsion  of  the  Tonsils. — The  nature  of  the  tonsils 
is  exi)laincd  (Glands  7)^  as  round  bodies  placed  on  each  side  of 
the  throat  to  absorb  the  secretions  from  the  head  and  send  them 
back  there  again,  and  to  do  likewise  for  the  vapors.  From  acute 
and  chronic  inflammations  they  may  become  greatly  swollen.  For 
enlarged  tonsils  he  advised  evulsion  with  the  fingers.  Although 
we  find  in  Hippocrates  no  mention  of  tonsillotomy,  it  is  evident, 
from  what  is  thought  to  be  a  genuine  book  of  Hippocrates,  viz: 
(The  Prognostics,  No.  23)*  that  he  was  familiar  with  uvulotomy. 
In  a  book  of  less  assured  authenticity  we  read  his  description  of 
the  operation:  "When  the  uvula  alone  is  inflamed  seize  it  with 
the  finger  and  ])ress  it  up  against  the  })alatc  and  cut  ofi'  the  end."^ 

Fractures  of  the  Nose. — As  has  been  intimated  the  Greek  physician 
had  every  opportunity  of  familiarizing  himself  with  fractures  of 

'  For  accounts  of  the  pneumatic  dogma  and  the  jjueumatists,  see  any  of  the 
histories  of  ancient  medicine. 

2  Des  Maladies,  VII,  p.  49.  =•  Des  Glandes.  VIII,  p.  5G1. 

•'  The  Prognostics,  I,  p.  210.  ^  Des  Maladies,  11,  29;  (Littre)  VII,  p.  47. 


FRACTURES  OF  THE  NOSE  53 

the  nose.  The  Hippocratic  writers  devote  much  attention  to  it. 
In  "MochKcus"  2/  Articulations  35,  36,  37,  38,  39,^  we  find  minute 
and  practical  directions  for  its  treatment.  Indeed,  comparatively 
little  advance  has  ever  been  made  over  their  methods.  Great 
stress  is  laid  upon  the  necessity  of  replacement  within  the  first 
twenty-four  or  thirty-six  hours  after  the  injury.  Satisfactory 
adaptation  of  the  parts  must  be  attained  notwithstanding  the 
patient's  suffering,  if  a  good  result  is  to  be  reached.  Hippocrates 
complains  bitterly  that  the  patient  strongly  desires  the  latter 
without  being  willing  to  submit  to  the  former.  For  lifting  the 
fragments  of  bone  into  place  he  preferred  the  fingers,  making  use 
of  those  of  some  boy  or  woman  assistant,  if  possible,  because  of 
their  small  size  and  their  softness.  Internal  splints  from  "Car- 
thaginian leather"  or  other  suitable  substances  were  used.  He 
condemns  the  use  of  sponges  for  the  purpose  because  they  soon 
become  foul  with  the  discharges.     He  relates  how  in  one  case  he 

Fig.  1 


From  Galeni  Opera  Omnia,  Venetiis,  1586,  Vol.  6,  f.  299,  B. 

made  use  of  a  piece  of  the  lung  of  a  sheep,  probably  as  a  temporary 
expedient.  Sacrificial  altars  to  the  gods  were  always  near  the  fields 
where  the  games  were  held  in  which  many  of  these  accidents 
occurred,  and  we  may  imagine  the  resourceful  surgeon  quickly 
cutting  a  piece  of  the  soft  elastic  tissues  from  the  open  chest  of 
the  slaughtered  victim  and  inserting  it  into  the  nostril  of  some 
vanquished  athlete.  ^Yhile  perhaps  it  is  not  so  curious,  a  more 
valuable  suggestion  is  contained  in  his  description  of  the  method 
of  treating  lateral  displacements  of  the  nose,  of  course  when  recent. 
An  internal  splint  was  inserted  as  usual  and  then  a  long  leather 
thong  was  glued  at  one  end  to  the  point  of  the  nose  which  was 
pulled  beyond  the  median  line  to  the  opposite  side,  and  the  thong 
wound  aroimd  the  head  and  fastened  by  gluing  to  the  temples  or 
in  some  other  convenient  fashion.  This  could  then  be  pulled  more 
taut  or  loosened  as  occasion  required.     It  is  not  certain  when  it 

ijVIochlicus  (Adams),  II,  p.  163.  -Articulations,  II,  p.  109-113. 


54  THE  HIPPOCRATIC  TREATISES 

first  occurred  to  surgeons  in  tamponing  the  nose  to  employ  cannulte 
that  the  patient  could  preserve  nasal  breathing.  I  am  not  aware 
that  it  is  to  be  found  in  the  Ilippocratic  writings,  but  in  those  of 
the  Roman  writers,  especially  the  later  ones  and  in  those  of  the 
Arabians,  a  goose  quill  wra])])ed  in  linen,  on  which  were  ai)i)lied 
salves  of  odoriferous  material  or  honey  mixed  with  the  mineral 
astringents,  the  salts  of  copper  and  iron,  is  tlie  c\ cr  recurring 
recommendation  for  internal  nasal  splints  in  cases  of  fracture  of 
the  nasal  bones. 

Hippocrates^  indulges  in  some  satirical  and  still  instructive 
remarks  concerning  bandages  for  a  fractured  nose. 

"Those  who  put  great  store  by  a  senseless  dexterity  rejoice  to 
meet  with  a  fracture  of  the  nose  in  order  to  apply  a  l)andage.  For 
a  day  or  two  the  physician  takes  great  pride  in  himself,  and  the 
patient  rejoices;  but  the  latter  soon  tires  of  wearing  the  bandage, 
which  is  annoying;  as  for  the  doctor,  it  is  enough  for  him  to  have 
shown  that  he  understands  how  to  put  various  bandages  on  the 
nose.  Such  a  bandage  does,  however,  quite  the  contrary  to  what 
is  desired;  on  the  one  hand,  in  those  in  whom  the  nose  had  been 
sunken,  it  becomes  markedly  more  sunken  if  pressure  is  exerted 
over  it;  on  the  other  hand,  in  those  in  whom  the  nose  has  been 
dislocated  to  the  right  or  to  the  left,  either  in  the  cartilaginous,  or 
in  the  upper  part,  these,  evidently,  far  from  deriving  any  advantage 
from  a  bandage  placed  on  it,  sufl'er  harm  from  it."  We  look  in 
vain  for  any  reference  to  operation  for  straightening  a  chronic 
deviation  of  the  septum.  It  is  a  little  surprising  that  with  the 
experience  derived  from  the  treatment  of  recent  fractures  and 
dislocations  of  the  nose,  they  should  ha^•e  failcfl  to  remedy  the 
chronic  lesion  which  must  have  been  frequent  enough.  He  insists 
that  external  wounds  or  comminution  of  the  fracture  are  not  con- 
traindications to  his  plan  of  treatmcMit.  He  must  have  witnessed 
the  results  of  tremendous  blows,  i)r()bably  with  the  cruel  cestus,  the 
iron  shod  glove  of  the  boxer,  for  he  speaks  of  the  sinking  in  of  the 
bridge  of  the  nose  when  there  is  also  exfoliation  of  the  })one  of 
the  hard  palate.  Evidently  in  these  dangerous  encounters  fracture 
at  the  base  of  the  skull  was  an  occasional  result.  At  least  he  was 
familiar  with  its  characteristic  symjjtom,  for  he  says:  "A  con- 
tusion of  the  head  without  an  external  wountl,  either  by  fall, 
fracture,  or  compression,  produces  in  some  cases  the  flow  of  acrid 
humors  which  run  from  the  head  into  the  throat."  Possibly,  how- 
ever, he  may  here  refer  to  suppuration  as  a  result  of  intranasal 
fracture.  2 

Syphihs  (?). — We  have  just  seen  that  Hippocrates  was  familiar 
with  depression  of  the  nasal  arch  as  the  result  of  injury.    That  he 

'Articulations,  3.5;  (Adams)  II,  p.  lU'J. 

2  These  excerpts  from  fractures  of  the  nose  I  have  taken  from  Adams'  trans- 
ation  of  the  Genuine  Works  of  Tlippocrates. 


NASAL  POLYPI  55 

was  familiar  with  it  as  the  result  of  disease  would  appear  from^ 
the  relations  of  the  cases  of  two^  children  who  from  ulceration 
lost  their  teeth  and  pieces  of  the  bone  of  the  palate.  This  caused 
a  sinking  of  the  nose.  They  also  had  a  bloody  mucopurulent 
discharge.  This  description  sounds  very  much  like  that  of  syphilis, 
either  congenital  or  tertiary.  This  is  thought  by  the  majority  of 
writers  to  have  appeared  first  in  Europe  two  thousand  years  later, 
brought  from  America  by  Columbus'  sailors.  This  sinking  of  the 
nose  is  again  referred  to  in  another  place. ^  It  is  to  be  gathered 
from  Galen's  commentary*  that  he  also  was  familiar  with  a  sinking 
in  of  the  bridge  of  the  nose,  due  to  a  loss  of  substance  in  the  struc- 
tures beneath.  Daremberg'  has  suggested  that  syphilis  is  the 
disease  referred  to  by  Hesiod  (Fragm.  27,  28),  who  betrays  a  knowl- 
edge of  some  skin  diseases  in  aphrodisiac  women.  After  a  perusal 
of  the  text  alluded  to,  it  seems  to  me  very  doubtful  if  this  was  the 
Corona  Veneris  as  Daremberg  surmises,  though  crusts  and  blotches 
were  found  in  the  scalps  of  these  women.  The  passages  here  cited 
from  the  Hippocratic  writings  and  from  Galen  seem  much  better 
evidence  of  it.  We  are  unfamiliar  today  with  any  other  disease 
of  the  palate  and  gums  of  a  chronic  nature  which  is  accompanied 
by  exfoliation  of  bone  and  the  sinking  in  of  the  nasal  arch.  The 
nasal  arch  will  not  sink  from  the  loss  of  the  palate  bone,  except  the 
nasal  bones  themselves  are  affected  at  their  junction  with  the  bony 
septum.  Of  course  it  may  possibly  have  been  some  severe  case  of 
scurvy  or  phosphorus  poisoning,  but  producing  such  results  as  these 
it  seems  very  unlikely. 

^Yhile  the  records  of  antiquity  contain  descriptions  which  it  is 
difficult  to  know  whether  to  ascribe  to  leprosy  or  syphilis,  the 
trend  of  historical  opinion  in  the  last  ten  years  has  been  decidedly 
toward  the  belief  in  the  existence  of  a  world-wide  syphilis  in  the 
days  of  Hippocrates,  but  of  a  mild  and  sporadic  type.  This  leaves 
the  mystery  of  its  recrudescence  in  the  middle  ages  a  problem  of 
immunity  having  a  much  wider  scope  in  its  involvement  of  general 
principles  than  is  now  the  conventional  way  of  regarding  it.'' 

Nasal  Polypi. — Probably  there  is  nothing  in  the  Hippocratic 
books  so  familiar  to  the  modern  rhinologist  as  Hippocrates'  sponge 
method  of  removing  nasal  polypi.'  Indeed,  this  was  a  method 
practised  by  Voltolini  and  mentioned  in  his  text-book.^     Until 

1  Des  Epidemies,  IV,  19;  (Littre)  V,  p.  157. 

-  This  is  the  reading  of  Littre's  translation,  and  to  my  mind  that  of  Kiihn's 
text,  but  the  latter's  translation  refers  to  but  one  child. 

^  Des  Epidemies,  VI,  Sec.  I,  3;  (Littre)  V,  p.  267. 

'  Edit.  Kuhn:  Vol.  XVII,  Pars.  I,  p.  823. 

=  Etat  de  la  Medecine  entre  Homere  et  Hippocrate,  p.  3. 

^  See  Lancet,  August  24,  1912. 

'  Des  Maladies,  II,  33;  (Littre)  VII,  p.  51.  This  l)()ok,  from  which  I  have 
quoted  so  freely,  is  said  to  have  been  written  by  Draco  and  Thessalus,  sons 
of  Hippocrates. 

«  Die  Krankheiten  der  Nase,  Breslau,  1888. 


56 


THE  HIPPOCRATIC   TREATISES 


the  comparatively  recent  invention  of  the  steel  wire  snare,  it  com- 
pared favorably  with  other  methods  of  ablation.     An  interesting]: 


Fig.  2 


Fig.  3 


NASAL  POLYPI 
Fig.  4 


Fig. 


From  Baldewein. 

paper  on  the  "Rhinology  of  Hippocrates,"  by  Baldewein, ^  is  largely 
taken  up  with  a  discussion  of  the  various  methods  recommended 
by  Hippocrates  for  the  removal  of  nasal  polypi,  and  the  accompany- 
ing illustrations  elucidate  the  procedures  very  much.  There  were 
several  methods.  The  sponge  method  was  used  for  those  soft 
pendent  polypi  which  move  out  and  in  the  nostril  on  expiration 
and  inspiration.  It  consisted  of  tying  the  ends  of  three  or  four 
strings  to  a  sponge  cut  to  the  proper  size  and  shape.  The  other 
ends  knotted  together  were  fastened  to  the  eye  of  a  soft,  slender 
tin  or  leaden  probe  which  was  pushed  through  the  nose  into  the 
pharynx.     The  ends  of  the  strings  thus  secured  were  passed  o\er 

1  Zeitschrift  fur  Ohrenhoilkunde,  1895-96,  Bd.  XXVIII,  p.  101. 


58  THE  HIPPOCRATIC  TREATISES 

the  end  of  a  forked  probe  held  in  the  pharynx.  By  traction  across 
this,  the  sponge  was  dragged  into  the  pharynx,  if  successful,  bring- 
ing the  polyj)  with  it.  In  another  method  for  harder  growths, 
perhaps  our  fibrous  hypertrophies,  the  principle  of  the  snare  was 
emi)loyed.  The  looj)  of  a  sinew  was  adjusted  arountl  the  polyp, 
and  the  end  having  been  carried  to  the  pharynx  and  traction  made 
as  before,  evulsion  was  attained.  For  still  harder  growths  which 
Baldewein  conjectured  may  have  been  bony  cysts,  he  employed 
cauterization  with  a  hot  iron  through  a  hollow  tube  used  as  a 
speculum.  I  do  not  see  any  reason  for  imagining  this  procedure 
was  for  this  rare  form  of  intranasal  growth.  It  may  easily  ha\-e 
been  many  other  pathological  conditions,  more  likely  to  come 
frequently  under  the  observation  of  the  physician,  such  as  cartil- 
aginous spurs  and  hypertrophies.  He  speaks  of  a  fleshy  growth  in 
the  nostrils  which  he  calls  cancer,  to  be  treated  })y  the  cautery, 
but  as  he  says  nothing  about  the  strikingly  fatal  symptoms  which 
ensue  from  any  form  of  local  treatment  of  malignant  growth  of 
the  nose,  it  is  doubtful  if  this  term  is  equivalent  to  the  present 
acceptation  of  it.  He  doubtless  had  encountered  rhinoliths,  for 
he  speaks  of  something  in  the  nose  which,  when  you  touch  it  with 
a  probe,  sounds  like  a  stone.  For  this  he  recommended  an  external 
incision.  After  all  these  radical  operations  he  advised  the  applica- 
tion of  copperas  powder  and  the  insertion  of  tents  in  the  nostrils, 
smeared  with  oil  and  honey,  no  doubt  to  prevent  synechise  and 
stenosis.  I  think  that  all  rhinologists  will  agree  that  these  pro- 
cedures, for  the  time,  were  not  bad  intranasal  surgery. 

From  the  book  on  "Affections"  we  learn  that  all  diseases  come 
from  the  phlegm  and  the  bile.  The  Hindu  idea  was  that  all  bodily 
diseases  come  from  Wind,  Bile,  and  Phlegm.  Indeed,  there  are 
many  resemblances  in  this  book,  as  well  as  the  one  I  have  just 
quoted  from,  which  remind  us  of  the  Susruta.  Polypi  were  sup- 
posed to  be  caused  by  the  phlegm.  It  was  derangement  of  these 
elements  which  produced  diseases  according  to  the  Hippocratic 
authors.  These  books  are  not  supposed  to  have  been  written  !)y 
Hippocrates  himself.  Indeed,  he  explicitly  discourages  all  theorizing 
as  to  etiology  in  his  book  on  Ancient  ^Medicine. 

Epistaxis. — In  various  places  Hippocrates  has  much  to  say  of 
nasal  hemorrhage  as  a  symptom  in  many  diseases,  and  in  Airs, 
Waters,  and  Places  remarks  that  persons  under  thirty  years  of 
age  are  liable  to  severe  bleeding  at  the  nose  in  summer.  In  the 
Du  Regime  dans  les  maladies  aigiies  (Append ire  27)'  recommenda- 
tions for  stopping  ei)istaxis  include  cold  externally,  a  tent  in  the 
nostril,  styptics,  and  purging.  One  of  the  Aphorisms  shows  that 
he  was  familiar  with  vicarious  menstruation  as  a  cause  of  the  nose- 
bleed. "In  a  woman  when  there  is  a  stoppage  of  the  menses,  a 
discharge  of  blood  from  the  nose  is  good"  (V,  33).- 

1  (Littrc)  II,  p.  515.  =  (Adams)  II,  p.  241. 


FROM  HIPPOCRATES  TO  CELSUS  59 

Sinusitis  (?). — Various  other  references  to  diseases  of  the  upper 
air  passages  may  be  found  in  the  Aphorisms,  and  among  them 
one  (VI,  10)^  referring  evidently  to  the  symptoms  of  aural  or  nasal 
sinus  disease: 

"In  a  person  having  a  painful  spot  in  the  head,  with  intense 
cephalalgia,  pus  or  water,  running  from  the  nose  or  by  the  mouth 
or  at  the  ears,  removes  the  disease."  It  was  supposed,  as  we  have 
seen,  that  the  origin  of  this  discharge  was  the  brain.- 

The  last  of  the  Aphorisms  applies  with  especial  force  to  the 
nose  and  throat,  though  it  is  meant  of  course  to  be  of  general 
application  (VIII,  87).^  "Those  diseases  which  medicines  do  not 
cure,  the  knife  cures;  those  which  the  knife  cannot  cure,  fire  cures; 
those  which  fire  cannot  cure  are  to  be  reckoned  wholly  incurable." 
A  similar  apothegm  is  found  in  the  Hindu  Susruta. 

In  the  clinical  notes  which  go  under  the  title  of  Coan  Prog- 
nostics we  find  an  intimation  that  phthisis  pulmonalis  is  a  result 
at  times  of  nasal  catarrh,  cases  thus  arising  being  considered  most 
dangerous  of  all  (II,  XXI,  430).'*  This  is  a  superstition  which  still 
lingers  in  medicine  and  is  continally  reappearing  in  some  form  or 
other. 

There  is  a  passage  in  this  l)ook  which  is  of  considerable  value 
in  the  differential  diagnosis  of  hemoptysis,  especially  among  a 
people  who  drink  directly  from  brooks  and  springs  and  pools  in 
the  primitive  fashion  (II,  17).^  "In  those  in  whom  the  throat 
becomes  filled  with  blood  several  times,  day  and  night,  without 
preceding  pains  in  the  head  or  cough  or  vomiting  or  fever  or  pain 
in  the  chest  and  back,  look  in  the  nose  and  throat.  You  will  find 
there  either  a  w^ound  or  a  leech." 

It  must  be  borne  in  mind  that  there  are  many  other  passages 
in  the  Hippocratic  books  of  great  interest  to  the  laryngologist, 
but  I  have  alreadv  cited  enough  to  convince  the  reader  that  a 
compilation  of  them  all  would  make  a  brochure  on  the  diseases 
of  the  nose  and  throat  which  no  modern  student  of  laryngology 
could  afford  to  despise. 


FROM  HIPPOCRATES  TO  CELSUS. 

There  now  followed  a  period  of  more  than  four  hundred  years 
before  a  medical  work  was  given  to  the  world  which  was  destined 
to  survive  the  ravages  of  time,  the  vicissitudes  of  empire,  and  the 
vandalism  of  man,  and  to  transmit  to  us  at  first  hand  the  state  of 
medical  knowledge  in  the  Roman  world  at  the  zenith  of  its  power 

»  (Adams)  II,  p.  251. 

-  Vid.:  Galen's  Commentary.     Edit.  Kuhn:  XVIII,  Pars.  I,  p.  20. 

^  (Adams)  II,  p.  273.  ^Pr^notions  Coaques,  V,  p.  681. 

^  (Littre)  V,  p.  653. 


60  FROM  HIPPOCRATES  TO  CELSUS 

and  vigor.  From  Hippocrates  to  Celsus  is  a  long  stretch  in  the 
history  of  the  world.  It  is  crowded  full  of  events  of  absorbing 
interest  and  importance  to  our  present  civilization.  It  witnessed 
the  rise  and  glory  of  Grecian  civilization  and  its  absorption  into 
the  world-wide  domain  of  imperial  Rome.  In  the  Ilippocratic  era 
tiny  Greece  was  battling  with  that  huge  menacing  bulk  of  Oriental 
despotism,  the  enervating  and  soul-enslaving  empire  of  the  Persian 
kings.  In  that  death  struggle  for  our  civilization  she  rolled  back 
from  ]\Iarathon  (490  B.C.),  Platea  (479  B.C.),  and  Salamis  (480 
B.C.)  that  tide  of  stifling  slavery  and  voluptuous  sensuality,  which 
was  threatening  to  engulf  the  garden  she  had  planted  and  to  extin- 
guish the  torch  she  had  lighted  at  fires  long  since  quenched  by  this 
very  Orientalism.  From  the  rugged  mountains  and  wind-swept 
isles  of  Greece  this  eastern  terror  recoiled  to  the  plains  of  Asia. 
Ninety  years  later,  ten  thousand  Greeks,  a  mere  handful  among 
millions,  marched  fifteen  hundred  miles  into  the  heart  of  the 
Persian  empire  and  after  putting  to  flight  an  army  of  a  million  men 
turned  around  and  cut  their  way  out  again.  When  next  they 
plunged  into  Asia,  seventy  years  later,  it  was  with  the  youthful 
Alexander  at  their  head.  They  dismembered  the  lifeless  body  of 
Orientalism  which  had  been  so  long  a  menace  to  them,  and  for  a 
thousand  years  it  lay  prostrate  before  it  again  threatened  the 
civilization  of  Europe.  When  it  was  again  about  to  inundate  the 
budding  civilization  of  the  west,  Don  John,  of  Austria,  at  Lepanto 
(1571),  and  John  Sobieski  with  his  Poles,  at  Vienna  (1583),  again 
stemmed  the  rising  tide  and  forced  it  back.  In  the  century  which 
now  opens  before  us,  the  drama  of  two  civilizations  played  on  the 
stage  of  the  world  for  twenty-five  hundred  years  by  the  immortal 
gods  is,  let  us  hope,  drawing  to  a  close.  Although  the  ancient 
Greeks  shattered  the  cohesiveness  of  the  mighty  Persian  empire 
they  could  not  graft  on  the  barren  limbs  of  Orientalism  the  buds 
of  their  own  fructifying  activity.  In  vain  did  the  generals  of 
Alexander  and  their  successors  call  around  them  the  most  brilliant 
minds  of  the  age. 

The  Schools  of  Pergamos  and  Alexandria. — The  libraries  of  Perg- 
amos  and  Alexandria,  with  their  hundreds  of  thousands  of  volumes, 
and  the  great  schools  which  were  founded  with  lavish  expenditure 
of  Oriental  treasure  wrung  from  slavish  races  by  their  Grecian 
rulers,  advanced  enormously  the  state  of  medical  knowledge,  but 
these  institutions  with  the  records  of  their  own  and  of  past  scientific 
labor,  planted  in  a  land  powerless  to  defend  them,  perished  utterly 
at  the  hands  of  a  succession  of  ruthless  Roman  and  Saracen  con- 
querors. The  universal  prevalence  of  the  spirit  which  creates  such 
monuments  is  the  only  bulwark  which  can  defend  them.^     As 

1  II  n'y  a  pas  de  syst^me  qui  puisse  durer  autremcnt  que  par  des  institutions. 
(Guizot.) 


ANATOMY  61 

Gibbon  suggests^  the  loss  to  literature  pure  and  simple  was  probably 
not  great,  but  to  medicine  and  science  it  was  irreparable,  for  only 
in  such  a  collection  of  books  can  we  hope  to  find  those  of  ancient 
date  which  appeal  to  the  understanding  of  man  rather  than  to 
his  emotions.  It  is  the  historian  of  science  alone  who  fully  realizes 
that  the  destruction  of  the  great  libraries  accomplished  greater 
wrong  to  humanity  a  thousand  times  over  than  any  event  history 
records.  The  great  poets,  historians,  dramatists  have  many  of 
them  been  preserved  to  us,  but  not  so  the  records  of  those  parts 
of  civilization  which  administer  directly  to  man's  material  comfort 
and  health,  and  thus  indirectly  to  his  happiness.^ 

We  are  reduced,  therefore,  again  to  the  necessity  of  scanning 
secular  literature  and  of  extracting  second  hand  from  the  later 
works  of  Galen,  Pliny,  Oribasius,  Rufus,  iEtius  the  scanty  records 
of  the  labors  of  more  original  workers  than  they. 

Anatomy. — -We  have  every  reason  to  believe  that  enormous 
strides  were  made  in  anatomy  by  the  schools  of  Alexandria  where 
dissection  of  the  human  body  was  first  certainly  regularly  pursued. 
It  is  even  said  that  the  school  of  Alexandria  indulged  in  the  practice 
of  human  vivisection.^  This  is  related  with  a  shudder  by  the 
historians  who  delight  to  report  the  innumerable  tortures  inflicted 
upon  innocent  men  by  their  fellow-men  from  motives  of  ambition, 
pride,  lust,  and  revenge.  The  statement  is  received  with  horror 
by  a  cultured  and  refined  public,  who  peruse  with  pleasure  and 
avidity  the  other  pages  of  history  reeking  with  gore  and  replete 
with  accounts  of  human  misery.  Erasistratus,  Herophilus,  and 
their  confreres,  if  they  did  it  at  all,  seemed  to  have  pursued  their 
investigations  on  gentle  murderers  and  other  virtuous  criminals, 
out  of  the  reprehensible  motives  of  enlarging  the  boundaries  of 
human  knowledge  and  increasing  the  powers  of  man's  benevolence 
and  humanity.  This  practice  attributed  to  the  Alexandrian  school 
has  been  denied  and  certainly  not  satisfactorily  proven.  Dis- 
section of  the  dead  human  body  as  well  as  of  animals,  however, 
did,  at  this  period,  create  the  science  oiHnatomy.  The  records 
of  this  fruitful  activity  have,  as  has  been  said,  utterly  perished, 
but  we  may  see  from  th^.  works  of  Hippocrates  and  of  Aristotle 
how  deficient  was  the  knowledge  of  human  anatomy  before,  and 
from  the  Avorks  of  Galen  how  enormously  increased  it  was  after 
the  foundation  of  the  libraries  and  schools  of  Pergamos  and 
Alexandria. 

Singular  to  say,  Aristotle  (384-322  B.C.),  who  dominated  the 
medicine  and  the  philosophy  of  the  dark  ages,  and  who  was  said 
to  have  long  practised  physic  before  he  devoted  himself  to  pure 

'  The  History  of  the  Dechne  and  Fall  of  the  Roman  Empire,  Vol.  V,  p.  228. 
-  The  School  and  the  Library  of  Alexandria  was  founded  320  b.c.  by  the 
Ptolemies  and  was  finally  destroyed  640  a.d. 
^  Celsus:  De  Medicina,  Lib.  L,  Pracfatio. 


C2  FROM  HIPPOCRATES  TO  CELSUS 

science,  has  left  behind  him  very  little  pertaining  directly  to 
medicine,  notwithstanding  his  profnse  contributions  to  nearly  all 
other  branches  of  knowledge.  Nevertheless  we  may  find  in  his 
works  a  few  indications  of  his  conception  of  the  anatomy  of  the 
upper  air  passages.  He  placed  at  the  top  of  the  nostrils  a  kind  of 
a  lid  which  rises  at  the  time  of  inspiration  to  let  in  the  odors. 
"There  is  no  passage  from  the  ear  to  the  brain,  but  there  is  to  the 
roof  of  the  mouth."  He  described  the  larynx  as  the  organ  through 
which  the  voice  and  the  breath  pass,  and  as  situated  in  the  front 
part  of  the  neck.  He  says  the  trachea  is  cartilaginous  and  surrounded 
by  smooth  rings  and  contains  but  little  blood.  "  It  lies  at  the 
upper  part  toward  the  mouth  opposite  the  passage  from  the  nostril 
to  the  mouth,  wherefore  if  any  liquid  is  drawn  into  it  in  drinking 
it  passes  out  of  the  mouth  through  the  nostrils."  "Between  the 
passages  is  the  epiglottis,  which  can  be  folded  over  the  passage 
which  extends  from  the  trachea  to  the  mouth;  by  the  epiglottis 
the  passage  of  the  tongue  is  closed;  at  the  other  extremity  the 
trachea  reaches  to  the  middle  of  the  lungs."  "The  heart  is  con- 
nected with  the  trachea  by  fatty  cartilaginous  muscular  bands." 
The  uvula  is  described  as  a  very  vascular  organ.  He  speaks  of 
the  epiglottis  as  part  of  the  tongue.  He  recognized^  that  the  voice 
was  produced  within  the  trachea  by  the  impact  of  the  air,  inspired 
by  the  soul  which  he  taught  resided  in  the  heart  and  lungs,  against 
it.  "It  is  the  voice  and  the  larynx  which  emits  vowels;  it  is  the 
tongue  and  the  lips  which  form  the  consonants,  or  the  aphonic 
letters."-  As  we  have  seen  (1.  c.),  Aristotle  was  free  from  the 
error  of  supposing  that  drink  passes  into  the  lungs. 

Praxagoras  was  the  last  of  the  iEsclepiadje  of  whom  we  have 
record.  We  read  in  "Coelius  Aurelianus^  that  he  recommended 
cutting  off  the  end  of  the  u^'ula  or  scarifying  it  deeply  when  it  was 
greatly  inflamed.  He  transmitted  the  medicine  of  Hippocrates 
to  his  pupil  Herophilus  (300  B.C.),  the  great  anatomist  of  the 
Alexandrian  school.  He  is  said  to  have  instructed  the  latter  in  the 
knowledge  of  the  pulse,  which  he  afterward  so  greatly  developed. 
Pliny  refers  to  Herophilus  as  the  "vatis  medincin.e,"^  the  oracle 
of  medicine.  He,  in  all  probability,  contril)uted  greatly  to  the 
anatomical  knowledge  of  the  upper  air  passages,  but  only  the 
merest  hints  of  it  remain  to  us.  Thus  we  learn  from  Rufus  Ephe- 
sius^  that  he  called  the  hyoid  bone  the  parastate  because  it  was 
situated  near  the  tonsils.  According  to  Soranus,  quoted  by  Ori- 
basius  (XXIV,  C  31),  Herophilus  likened  the  cervix  uteri  gravidi 
to  the  larynx.    Plutarch,  from  whom  we  have  so  often  to  quote, 

1  Df  Anima:  II,  VIII,  vid.  Translat  on  by  St.  Hilaire  Trait6  de  I'Amo,  p.  225. 

2  Hist,  of  Animals,  IV,  Chap.  IX.  '  De  Morb.  Acut.,  Ill,  C.  IV. 

*  Hist.  Nat.,  Lib.  XI,  Cap.  37. 

*  CEuvros  de  Rufus  d'Ephese  (Daremberg),  Paris,  1879.  Du  Xom  des 
Parties  du  Corps,  p.  155. 


ROMAN  MEDICINE  63 

after  mentioning^  some  incomprehensible  theories  of  Empedocles 
and  of  Asclepiades,  says  that  Herophihis  attributes  a  moving 
faculty  to  the  nerves,  arteries,  and  muscles,  but  believes  that  the 
lungs  are  affected  only  with  a  natural  desire  of  enlarging  and 
contracting  themselves.  From  the  citation  made  by  Marx  in  his 
brochure  on  Herophihis  (p.  34),  I  would  infer  that  the  latter  thought 
that  the  lung  drove  the  air  into  the  pleural  cavity,  and  then, 
receiving  it  back  again,  expelled  it  externally.  Erasistratus  and 
Herophihis  both  knew  that  the  arteries  contained  blood  and  that 
the  pulse  was  connected  with  the  heart,  and  yet  apparently  the 
circulation  of  the  blood  remained  unknown  for  eighteen  centuries. 
We  learn  from  Celsus-  that  the  former  used  ligation  of  the  extrem- 
ities as  a  remedy  for  hemoptysis.  Eudemis  (279  B.C.),  we  learn 
from  Rufus,''  compared  the  styloid  process  to  the  spur  of  a  cock, 
but  gave  it  no  name.  This  is  a  small  gleaning  from  a  period  of 
several  hundred  years  which  marked  the  beginnings  of  the  study 
of  anatomy,  but  as  to  the  upper  air  passages  we  look  in  vain  for 
more,  at  least  until  the  time  of  Asclepiades. 


ROMAN  MEDICINE. 

Pliny  is  often  quoted  as  saying  that  Rome  for  GOO  years  was 
without  physicians  but  not  without  physic.  Cato,  the  Censor 
(b.  232  B.C.),  we  know  had  a  very  poor  opinion  of  the  doctors  and 
in  fact  of  learning  in  general.  He  was  instrumental  in  driving  Car- 
neades  and  the  other  Greek  savants  from  Rome  in  his  day,  but 
it  cannot  be  conjectured  that  this  arose  from  any  skeptical  turn  of 
mind  on  his  part,  for  in  his  book  on  Agriculture,  amidst  many 
receipts,  amulets,  charms,  and  invocations  we  find  him  prescribing 
his  favorite,  almost  his  sole,  drug  for  nasal  polypus:  "If  there  is 
a  polypus  in  the  nose  rub  together  some  dry  wild  cabbage  leaves 
in  the  hand  and  place  it  at  the  nose  and  draw  up  the  breath  as 
much  as  you  can.  In  three  days  the  polypus  will  fall  away.  Never- 
theless, for  some  days  do  the  same;  so  that  you  may  render  the 
roots  of  the  polypi  entirely  healthy." 

It  was  not  until  the  year  219  B.C.  that  Greek  medicine  found  its 
way  to  Rome.  Archagathus  w^as  the  first  Greek  physician,  who, 
about  that  time,  came  to  Rome.^  He  was  very  unsuccessful.  We 
may  read  in  Plutarch's  Life  of  Cato,  the  Censor,  how  the  Romans 
treated  Carneades,  the  Athenian  philosopher  and  Ambassador, 
in  order  to  appreciate  the  prejudice  with  which  the  sturdy  but 

1  De  Placit,  Philosoph.,  XXII.  =  Dq  Medicina,  Lib.  IV,  Cap.  12. 

^  OEuvres  (Daremberg),  p.  152. 

^  Cassius  Hemina,  among  the  most  ancient  authors,  is  authority  for  the 
report  that  the  first  of  physicians  to  come  to  Rome  from  the  P(>loponcssus  was 
Archagathus,  the  son  of  Lysania,  in  the  year  of  the  City,  535. — (Plinii  Naturahs 
Hist.,  Lib.  XXIX,  Cap.  1-6.) 


64  ROMAN  MEDICINE 

rude  old  patricians  of  ancient  Rome  viewed  the  introduction  of 
Greek  civilization.  It  has  always  been  noted  in  tlie  history  of 
the  world  that  the  first  advances  which  have  tended  to  ameliorate 
the  asperities,  to  increase  the  amenities,  and  to  introduce  a  wider 
knowledge  among  a  rude  and  vigorous  people  have  met  with  the 
suspicion  and  contempt  of  the  conservative  majority,  who  look 
upon  the  innovations  as  the  first  steps  toward  effeminacy  and 
degeneration. 

Cicero's  Anatomy  and  Physiology. — It  was  not  until  the  time  of 
Asclepiades  (100  B.C.)  the  friend  of  Cicero  (106-43  B.C.)  "is  quo 
nos  medico  amicoque  usi  sumus,  tum  eloquentia  vincebat  ceteros 
medicos"^  that  the  art  of  medicine  really  began  to  flourish  in  Rome, 
and  we  soon  find  Cicero  describing  the  wonders  wrought  by  the 
immortal  gods,^  not  the  least  of  which  are  the  marvels  of  the  human 
anatomy.  "  It  will  be  more  easily  appreciated  what  has  been  done 
for  man  by  the  immortal  gods,  if  the  whole  fabric  of  man  is  exam- 
ined, and  the  perfection  and  method  of  human  structure  is  brought 
to  our  comprehension.  The  life  of  living  creatures  is  maintained 
by  three  things,  by  food,  by  drink,  and  by  the  breath  (spiritus), 
and  for  making  use  of  these  the  mouth  is  especially  adapted  because 
it  is  reinforced  by  the  air  from  the  adjoined  nostrils.  The  food  is 
masticated  by  the  teeth  arranged  in  the  mouth,  and  by  them 
di\ided  and  softened.  The  sharp  front  teeth  divide  the  food  when 
bitten,  and  the  back  ones,  which  are  called  the  true  teeth,  prepare 
it,  and  this  preparation  seems  to  be  aided  even  by  the  tongue. 
The  oesophagus,  adherent  to  the  tongue  as  its  root,  receives  from  it 
that  which  has  been  received  by  the  mouth.  This,  touching  the 
tonsils  on  each  side,  is  continuous  with  the  end  of  the  palate  and 
this  it  is  Avhich  receives  the  food  after  it  has  been  pushed  along 
by  the  movements  of  the  tongue,  and  passes  it  downward.  Those 
parts  which  are  lower  down  than  that  which  swallows  (the  food) 
are  dilated,  while  those  parts  above  are  contracted.  But  since 
the  "Aspera  Arteria,"  for  thus  it  is  called  by  physicians,  has  an 
opening  joined  to  the  roots  of  the  tongue,  a  little  above  where  the 
oesophagus  is  joined  to  the  tongue,  and  since  this  reaches  to  the 
lungs  and  receives  the  air  (or  soul-anima)  that  being  received  from 
the  breath  (spiritus)  and  this  being  inspired  and  again  returned, 
it  is  protected,  as  it  were,  by  something  like  a  lid,  which  is  provided 
for  the  reason  that  if  l)y  any  chance  food  should  fall  in  it,  the  breath 
would  be  stopped.  Since  by  its  nature  the  belly,  attached  below 
to  the  esophagus,  is  a  receptacle  for  food  and  drink,  and  the  lungs 
and  heart  form  an  exit  for  the  breath,  in  the  belly  many  things 
are  admirably  arranged,  which  it  is  about  agreed,  are  (controlled) 
from  the  nerves  (nervis).  It  (i.  e.,  the  gastro-intestinal  tract)  is, 
however,  multiple  and  tortuous,  and  it  encloses  and  holds  that 

1  De  Oratore,  I  Cap.  14.  ^  Dq  Natura  Deorum,  II,  54. 


ASCLEPIADES  65 

which  it  receives  whether  it  is  dry  or  wet,  so  that  it  may  be  altered 
and  digested;  it  is  by  turns  contracted  and  relaxed,  and  everything 
which  it  receives  it  compresses  and  mixes,  so  that  all  things,  pre- 
pared and  digested  by  the  heat,  of  which  it  has  much,  and  by  the 
attrition  of  the  food  and  especially  by  the  breath  (spiritus),  are 
distributed  to  the  rest  of  the  body.  In  the  lungs,  however,  there 
is  a  certain  looseness  of  texture  and  a  softness,  similar  to  the 
sponges,  most  carefully  adapted  for  drawing  in  the  breath.  They 
in  turn  contract  on  expiration  and  dilate  on  inspiration,  so  that 
the  nourishment  by  which  breathing  creatures  are  principally 
supported  may  be  frequently  taken  in." 

In  another  passage  (Ibid.,  Lib.  II,  Cap.  57)  Cicero  intimates  the 
existence  of  further  knowledge  of  nasal  physiology  in  his  remark: 
"Likewise  the  nares,  which  are  always  open  on  account  of  neces- 
sary functions,  have  narrower  entrances  lest  anything  which  might 
be  injurious  should  enter  them,  and  they  always  are  supplied  with 
a  moisture  not  useless  for  arresting  dust  and  many  other  things." 
Of  course  we  cannot  suppose  that  Cicero  included  bacteria  in  his 
"multaque  alia  depellenda." 

After  all,  these  passages  from  one  of  the  greatest  masters  of 
human  speech  who  has  ever  lived,  and  a  man  profoundly  imbued 
with  all  the  knowledge  of  his  day,  are  perhaps  not  a  bad  index  of 
the  state  of  knowledge  of  the  anatomy  and  physiology  of  the  air 
and  food  tracts.  It  is  a  great  advance  over  anything  we  can  find 
in  Hippocrates  and  Aristotle. 

Asclepiades. — As  to  Asclepiades,  that  eloquent  rhetorician  of 
Bithynia,  the  friend  of  Cicero  and  Crassus,  the  great  advocate  of 
diet,  exercise,  and  massage,  and  enemy  of  bitter  doses  and  radical 
treatment  generally,  we  have  only  a  few  fragments,  collected  by 
Gumpert.  He  made  a  great  stir  in  his  day;  he  declared  that  so 
perfect  was  his  regimen,  disease  had  no  terrors  for  him;  he  was 
never  sick  and  only  died  because  he  fell  from  a  ladder  and  broke 
his  neck  in  extreme  old  age.^  Synanche-  he  said  was  "a  flow  of 
the  humors  or  a  wetness  of  the  fauces,  or  rather  of  the  very  top 
of  them,  coming  down  from  the  head."  Besides  the  purging  and 
bleeding  he  scarified  the  tonsils  and  the  fauces  around  them. 
]Moreo^'er,  he  approved  of  the  practice  of  incision  of  the  trachea  as 
recommended  by  the  ancients,  which  they  called  lar^'ngotomy,' 

1  Pliny:  Hist.  Natur.,  Lib.  VII,  Cap.  37. 

2  Coelius  Aurel.  de  Morb.  Acut.  Ill,  1  (Amman),  Amst.,  1709,  p.  181. 

^  Coelius  Am-elianus  (de  Morb.  Acut.),  Lib.  Ill,  Cap.  IV,  Edit,  .\mman, 
p.  193 — Asclepiades — At  si  major  (inquit)  passio  fuerit,  dividendai  sunt  fauces, 
hoc  est  tonsillae  et  partes  supra  uvam  constitutse,  etenim  summa  est  in  his 
sequalis  sive  par  incisura,  quam  appelavit  homatomia.  Dehinc  a  veteribus 
probatum  approbat  arterise  divi.suram,  ob  rcspirationom  faciendam,  quam 
laryngotomiam  vocant,  varie  ao  multiplicitcr  pcccans. 

This  is  the  first  mention  we  find  of  this  operation  unless  it  is  referred  to  in 
the  Talmud.  It  is  a  good  illustration  of  how  much  must  have  been  lost  from 
the  old  records.  Coelius  expresses  the  belief  that  the  account  of  the  ancients 
doing  it  was  not  true  but  an  invention  of  Asclepiades. 

5 


66  CELSUS  AND   THE  PRE-GALENIC   WRITERS 

to  relieve  the  respiration.  Themison,  the  founder  of  the  school  of 
Methodists  and  a  follower  and  disei])leof  Asclepiades,  also  approved 
of  this  surgical  operation.  Celsus  (Lib.  1\ ,  Cap.  IX),  quotes  him 
approvingly  and  recommends  his  prescription  of  swallowing  strong 
vinegar  in  ulceration  of  the  fauces,  and  says  that  he  condemned 
the  practice  of  Erasistratus  ligating  the  extremities  for  hemoptysis. 
AYith  this  condemnation  Celsus  does  not  agree.  So  far  as  the 
throat  is  concerned,  therefore,  his  practice  to-day  would  not  be 
called  very  mild  or  conservative. 


CELSUS  AND  THE  PRE-GALENIC  WRITERS. 

In  the  eight  books  of  the  "De  jNIedicina,"  which  remain  to  us 
from  the  writings  of  Aulus  Cornelius  Celsus,  who  was  probably 
born  in  the  last  da^'s  of  the  reign  of  Caesar  Augustus,  about  the 
beginning  of  the  Christian  era,  are  found  several  chapters  which 
deal  with  the  diseases  of  the  upper  air  passages.  Written  by  a 
Roman  patrician,  it  is  the  first  and  almost  the  only  work  of  medicine 
which  has  come  down  to  us  written  in  the  Latin  tongue  as  used  bv 
Virgil  and  Horace,^  and  all  that  brilliant  coterie  of  men  who  adorned 
the  imperial  courts  of  Augustus  and  Tiberius,  and  sauntered 
through  the  gardens  of  Maecenas.  As  an  interpreter  of  Hippocrates 
he  was  profoundly  influenced  by  the  precepts  of  Asclepiades,  but 
he  evidently  was  a  man  of  virile  understanding  and  original  powers, 
whose  W'Orks  still  contain  much  of  value  to  the  surgeon. 

Coryza.— In  his  chapter  on  coryza,^  he  repeats  the  conviction 
of  Hippocrates  that  some  cases  of  phthisis  owe  their  origin  to 
catarrh  of  the  upper  air  passages.  "Destillat  autem  humor  de 
capite  interdum  in  nares,  quod  leve  est;  interdum  in  fauces,  quod 
pejus  est;  interdum  etiam  in  pulmonen  quod  pessimum  est."  For 
him,  as  for  Hippocrates  before  him  and  Galen  after  him,  the  humor 
dripped  through  the  cribriform  plate.  So  far  as  the  coryza  is  con- 
cerned, indeed,  he  says,  there  is  nothing  pestiferous  about  it  unless 
it  ulcerates  the  lungs.     He  recommended  as  treatment  abstention 

^  The  following  lines  have  been  held  by  some  medical  historians  to  refer  to 
the  physician  Celsus,  but  there  seems  every  reason  to  believe  it  was  the  some- 
what earlier  poet  Celsus  to  whom  Horace  here,  as  several  times  elsewhere, 
alludes : 

"Quid  mihi  Celsus  agit?  monitus  multumque  monendus 

Privatus  ut  querat  opes,  et  tangere  vitet 

Scripta  Palatinus  quecumque  recepit  Apollo, 

Ne  si  forte  suas  repetitum  venerit  olim 

Grex  aviimi  plumas  moveat  cornicula  risum 

Furtivis  nudata  coloribus." — (Horat.  Epist.  I,  3,  15.) 

We  see  by  this  extract  that  the  library  on  the  Palatine  Hill,  founded  by 
Augustus,  was  already  in  reciuisition  bj-  writers,  and  already  the  charge  of 
plagiarism  was  much  indulged  in  by  the  literati. 

2  Lib.  IV,  Cap.  II. 


ANGINA,  KYNANCHE,  SYNANCHE  67 

from  daily  routine  and  protection  from  the  weather,  as  well  as 
abstention  from  the  bath,  wine,  and  venery.  He  approved  of  active 
exercise  in  the  house  and  laid  great  stress  upon  massage.  He 
advised  against  overeating  and  recommended  that  only  a  half-pint 
of  water  a  day  be  taken  as  drink.  Warm  vapors,  the  head  and 
neck  wrapped  in  flannel,  and  especial  care  to  be  given  to  the  diet, 
were  also  urged.  These  prescriptions  were  varied  somewhat  as  the 
discharges  became  thicker,  but  at  all  stages  massage  and  exercise 
were  to  be  employed. 

Angina,  Kynanche,  Synanche. — ^In  regard  to  throat  inflammations,^ 
those  which  are  confined  to  the  fauces,  he  said,  the  Romans  called 
angina,  while  the  Greeks  gave  the  name  synanche  to  that  form  in 
which  there  was  dyspnoea  without  any  appearance  of  inflammation 
in  the  fauces,  and  cynanche  to  that  form  where  the  obstruction 
could  be  made  out  in  the  fauces.  The  Greeks  supposed  the  former 
condition  (i.  e.,  the  synanche)  to  be  due  to  the  disease  of  the 
"pneuma"  itself,  and  that  this  it  was  which  caused  a  collapse  of 
all  the  parts  of  the  chest  and  neck.- 

With  Celsus,  cupping,  bleeding,  purging  were  the  remedies 
employed,  the  cups  to  be  applied  around  the  fauces.  Hyssop, 
thyme,  absinthe,  bran,  or  dried  figs  steeped  in  water  w^ere  the  highly 
agreeable  gargles  he  used,  though  all  his  prescriptions  were  not  so 
mild.  Vinegar,  powdered  pe])per,  and  oxgall  also  formed  part  of 
his  pharmacopoeia.  In  certain  cases  he  made  deep  incisions  exter- 
nally beneath  the  jaws  and  bled  from  the  lingual  veins.  His 
incision  into  the  palate  above  the  uvula  (VI-X)  was  more  in 
accord  with  modern  practice  in  quinsy.  ^Yithout  the  necessary 
differentiation  of  diphtheria  from  quinsy  or  other  inflammatory 
processes,  we  can  readily  understand  his  remark  that  "  if  the 
patient  is  not  aided  by  these  things,  then  we  may  know  he  is  a 
victim  to  this  disease."  He  apologizes  for  mentioning  a  remedy, 
which  seems  later  to  have  been  very  popular  in  Rome  for  centuries, 
saying  that  it  w^as  somewhat  out  of  place  in  a  scientific  work. 
Pliny  and  Galen  mention  the  same  and  speak  highly  of  its  efficiency. 
A  swallow  either  fresh  or  salted,  ha\'ing  been  kept  thus  in  the  house 
for  the  purpose,  is  to  be  burned  to  a  cinder  and  the  ashes,  moistened 
in  water,  are  to  be  applied  to  the  throat  in  a  threatened  attack  of 
angina.  Pliny^  dwells  on  the  same  remedy  at  considerable  length, 
and  dilates  on  the  difference  in  the  efficacy  of  the  different  kinds 
of  swallows.    On  a  reference  to  the  Hindu  Susruta  (Vol.  H,  Gap. 

1  Lib.  IV,  Cap.  IV. 

2  There  seems  to  have  been  great  confusion  among  the  Greek  medical  writers 
at  this  date  in  the  use  of  the  two  terms.  Galen  in  his  Commentaries  on  the 
Prognostics  of  Hippocrates,  Opera  Omnia  (Ktihn),  XVIII,  Pars.  2,  p.  2()7, 
intimates  that  the  two  terms  arose  out  of  a  different  reading  of  the  initial  letter 
in  the  word,  as  uscfl  bj'  Hippocrates,  by  different  writers,  and  that  Hippocrates 
made  no  distinction.  This  is  probably  the  correct  explanation.  We  will  find 
Areteus  making  elaborate  distinctions  in  the  use  of  the  terms. 

^  Hist.  Animal,  XXX,  4,  12. 


68  CELSUS  AND  THE  PRE-GALENIC   WRITERS 

XXII)^  will  be  found  the  prototype  of  this  prescription.  "In 
affections  [of  the  throat]  arisinji;  from  the  blood  and  bile,  cure  is 
obtained  by  the  use  of  swallows."  This  is  one  of  the  many  instances 
of  the  Oriental  origin  of  this  sort  of  therapy.  Celsus  thinks  no 
apology  necessary  when  in  the  next  chapter  on  dyspnoea  he  recom- 
mends a  paste  made  of  dried  fox  liver  powdered.  lie  also  advises 
it  should  be  roasted  and  eaten.  Even  for  dyspnoea  he  recommends 
moderate  exercise  and  does  not  forget  massage. 

Diphtheria. — "By  far  the  most  perilous  of  all  ulcers  [of  the 
mouth]  are  those  which  the  Greeks  call  '\/0^«c,  chieHy  in  children, 
for  in  men  and  women  there  is  not  the  same  peril. "^  Evidently 
this  is  diphtheria.  He  remarks  that  ulceration  of  the  fauces  is 
frequently  followed  by  a  cough,  for  which,  of  every  description,  he 
recommended  long  sea  voyages,  sea-side  resorts,  and  sea  bathing.^ 
He  devotes  a  chapter^  to  the  spitting  of  blood  and  recognizes 
vicarious  menstruation  among  other  more  frequent  causes. 

Ozsena. — For  ulcerated  nares  he  recommended^  N'apor  of  hot 
w^ater  from  a  narrow-necked  vessel,  and  mineral  astringents  were 
applied  to  the  ulcer.  "  But  if  these  ulcers  are  around  the  openings 
and  the^'  have  manv  crusts  and  a  foul  odor,  which  \'arietv  the 
Greeks  call  "  Oyjcva,  it  should  be  recognized  that  it  is  hardly  possible 
to  cure  this  disease.  Nevertheless  these  things  may  be  tried;  let 
the  head  be  shaved  to  the  skin,  and  persistently  and  vigorously 
rubbed;  let  it  be  bathed  with  plenty  of  hot  water;  let  there  be  much 
walking;  moderate  food,  nothing  very  sharp  or  very  strong;  then 
in  the  nostrils  let  honey  be  applied  with  a  small  amount  of  the 
resin  of  turpentine,  which  may  be  used  on  a  probe  wrapped  with 
wool;  let  this  liquid  be  drawn  in  with  the  breath  until  the  taste 
of  it  is  perceived  in  the  mouth;  by  the  use  of  this  the  crusts  are 
loosened,  which  mav  then  be  removed  bv  the  use  of  sternutatories." 
How  accurate  this  prognosis  was  we  still  have  reason  to  know; 
how  excellent  the  local  treatment  was  we  still  bear  testimony  to 
in  our  present  therapy  of  irritating  applications  to  the  nostrils. 
We  recognize  here  another  method  of  treatment  which  has  been 
thought  to  be  entirely  modern.  He  advises  leaving  pledgets  of 
lint  saturated  with  some  medication  in  the  nostrils,  this  to  l)e  done 
twice  a  day  in  winter  and  spring  and  thrice  a  day  in  summer  and 
autumn." 

1  Susruta  (Hessler),  II,  p.  133. 

2  Celsus:  De  Mcdicina,  Lib.  VI,  Cap.  XI. 
^  Ibi<l.,  Lib.  IV,  Cap.  IV. 

*  Ibid.,  Lib.  IV,  Cap.  IV.  ^  Ibid.,  Lil).  VI,  Cap,  VIII. 

8  "  .  .  linimontum  involutum  ct  obloiifruiii  eodom  mcdicamcnto  illinen- 
dum,  de  mittendurnquo  in  narem,  et  ab  inferiore  j^artc  Icniter  dcligandum. 
Idque  per  hieinen  et  ver  bis  die;  per  estatem  et  autumnum  ter  die  fieri  debet." 
Bertherand:  Medicine  et  Hj^giene  des  Arabes,  18.5.5,  p.  502,  notes  the  treatment 
of  oza;na  amonp;  Arabs,  of  Algeria,  by  means  of  insertion  in  the  nostrils  of  a 
seton  of  wool  or  a  tuft  of  hair  soaked  in  honey  and  some  irritating  substance. 
These,  of  course,  are  what  we  know  as  Gottstein's  tampons. 


THE  THERAPY  OF  PLINY  69 

In  another  place^  he  describes  a  very  radical  surgical  operation 
for  the  cure  of  ozaena,  which  has  also  been  urged  by  at  least  one 
modern  author.^  Celsus  does  not,  however,  himself  indorse  the 
operation,  which  consisted  in  the  use  of  the  actual  cautery  through 
an  earthenware  tube  or  the  quill  of  a  writer's  pen,  and  the  affected 
parts  thoroughly  seared,  and  the  wound  dressed  with  astringent 
and  soothing  applications. 

Polypi. — Nasal  polypi,  which  he  likened  in  appearance  to  the 
nipples  of  a  female  breast,''  he  treated  by  caustics.  He  described 
them  as  showing  in  front  on  the  lip  and  sometimes  behind,  "by 
that  foramen  through  which  the  breath  descends  to  the  fauces," 
hanging  down  so  that  it  may  be  seen  behind  the  uvula,  and  in 
cold,  damp  days  it  strangles  a  man.  Some  he  calls  /.afixryiodr^^^ 
and  these  should  not  be  touched.  Elsewhere  he  shows  how  the 
other  kind  may  be  cured  by  operation.^  He  used  a  sharp  instrument 
like  a  spatula  to  separate  it  from  the  bone,  and  then  by  means  of 
a  hook  it  was  to  be  removed.  His  surgical  treatment  for  large  and 
hard  tonsils  was  to  separate  them  from  the  sides  of  the  throat  with 
the  finger^  and  tear  them  out,  or  drawing  them  inward  with  a 
hook  to  cut  them  off.  His  operation  for  uvulotomj'  has  not  been 
improved  upon.  He  cut  the  frenum  linguae  for  trouble  in  speak- 
ing, and  this  relieved  many,  but  he  had  seen  it  fail  once.  He  also 
was  familiar  with  ranula.  He  mentions  hare-lip,  and  elsewhere® 
describes  operations  for  the  cure  of  that  and  other  deformities 
about  the  face  by  plastic  methods.  He  operated  on  bronchocele 
by  making  an  incision  through  the  skin  and  shelling  the  tumor 
out  with  the  finger.^  It  may  be  easily  seen  from  these  few  extracts 
that  Celsus  was  well  entitled  to  the  name  which  has  been  given 
him — the  Roman  Hippocrates. 

The  Therapy  of  Pliny. — We  have  already  had  occasion  to  quote 
from  Pliny  knowledge  which  he  said  he  had  derived  from  the  INIagi. 
He  died  at  the  foot  of  ^Mount  Vesuvius  on  that  dreadful  day  (August 
25,  72  A.D.)  after  a  cloud  shaped  like  a  pine  tree  had  the  day  before 
shot  up  in  the  air  above  the  smoking  mountain.  It  was  seen  by 
Pliny  from  his  villa  on  the  shore  of  the  beautiful  Bay  of  Naples  at 
Misenum,  and  summoning  the  Roman  galleys  he  commanded,  he 
sailed  into  the  mephitic  vapors  to  rescue  his  terror-stricken  friends, 
and  perished  in  the  attempt.  Pompeii  and  Herculaneuni  lay  buried 
beneath  the  hot  ashes  and  cinders,  and  thus  kept  treasured  up  for 
eighteen  hundred  years  the  relics  of  the  power  and  pride  of  Rome, 
who  thought  herself  mistress  of  the  world,  to  excite  the  wonder 
and  curiosity  of  travelers  from  lands  she  had  never  dreamed  of. 
He  lay  dead  upon  the  shore,  a  brave  man  and  a  philosopher,  and 

1  De  Med.,  Lib.  VII,  Cap.  XI. 

-Rethi:  Arcli.  I'iir  Larviifiol.  und  Rhinol.,  Berlin,  1895,  II,  p.  194. 

3  De  Med.,  Lib.  VI,  Cap.  VIII.  ■•  Ibid.,  VII,  Cap.  X. 

5  Ibid.,  VII,  Cap.  XII.         «  Ibid.,  VII,  Cap.  IX.         '  Ibid.,  VII,  Cap.  XIII. 


70  CELSUS  AND   THE  PRE-GALENIC   WRITERS 

the  work  which  he  left  behind  him,  the  Ilistoria  Xatiirahs,  became 
all  throiijih  the  Middle  Ages  the  source  from  which  credidoiis 
humanity  deri\ed  its  pharmacopcria. 

In  the  Dark  Ages,  among  the  half-civilized  barbarians  who 
flooded  the  lioman  Empire  and  nearly  extinguished  the  torch 
of  civilization,  the  necromancy  and  the  filthy  drugs  of  Egypt 
and  Chaldea  found  the  ready  market  which  (Jrecian  culture  and 
Roman  civilization  in  the  better  ages  never  ottered.  The  entrails 
and  excreta  of  birds  and  reptiles  and  shell  fish,  all  manner  of 
fish,  bird,  and  beast,  besides  innumerable  plants  and  minerals, 
fill  page  after  page  of  Pliny's  treatise.  Large  numbers  are  recom- 
mended for  nose  and  throat  diseases,  with  very  little  discrimination 
as  to  the  affections  for  which  they  were  prescribed.  In  fact,  one 
pursues  the  record  of  drug  therapy  through  the  history  of  medicine 
with  very  little  profit.  One  may  sum  it  all  up  by  saying  that 
human  ingenuity  has  applied  all  medicaments  to  every  disease. 

Perhaps,  after  all,  the  best  definition  of  a  drug  is  that  inciden- 
tally given  by  jNIontaigne  in  boasting  of  the  health  of  his  progenitors: 
"  Eor  them  everything  which  was  not  in  ordinary  use  took  the  i)lace 
of  drugs."  For  an  illustration  of  these  remarks  one  may  turn  to 
Dioscorides,  whose  botanical  and  pharmacological  work  dates 
from  about  this  time.  Here  we  may  find  the  swallow  prescription 
in  manj^  forms,  not  only  for  anginas,  but  for  many  other  affections. 

The  Roman  Empire,  by  the  victories  of  Caesar  and  Pompey, 
had  undergone  an  immense  expansion.  All  roads  soon  led  to 
Rome.  Asclepiades  we  have  seen  as  the  friend  of  Crassus  and 
Cicero,  but  he  came  to  Rome  for  fame  and  practice  from  his  native 
Bithynia. 

Aretaeus. — It  is  not  certain  that  Aretaeus  lived  in  Rome,  though 
it  is  probable  he  was  acquainted  with  the  practice  of  Italy,  He 
was  a  native  of  Cappadocia.  Even  the  exact  date  of  the  medical 
activities  of  Aretaeus  seems  very  uncertain,  but  it  is  supposed  that 
he  lived  shortly  before  the  birth  of  Galen  {I'M  a.d.),  in  an  era 
extending  perhaps  from  the  reign  of  Titus  (79  a.d.)  to  that  of  the 
great  ]Marcus  Aurelius  (161  a.d.).  It  is  singular  that  so  few  con- 
temporary and  subsequent  medical  authors  mention  Aretaeus, 
whose  writings  in  perspicuity  of  observation  and  brilliancy  of 
execution  are  surpassed  by  none  in  the  history  of  medicine. 

The  Uvula. — Aretaeus'  chapter  on  diseases  of  the  uvula  is  an 
interesting  expose  of  the  ditt'erent  api)earances  presented  by  that 
organ  in  disease.  The  inflamed,  reddened  (rdcmatous  uvula;  the 
elongated  uvula,  sometimes  with  what  was  ai)])arcntly  a  papilloma 
at  the  end  of  it;  the  broad  uvula,  with  bat-like  wings  at  the  side — 
for  all  these  he  had  separate  names — besides  the  bifid  uvula,  for 
which  he  had  no  name  ("but  which  was  recognizable  by  all"), 
while  that  is  especially  the  form  to  which  we  moderns  Ikuc  given 
a  name.    He  also  described  a  condition  left  behind  after  an  oblique 


KYNANCHE  AND  SYNANCHE  71 

amputation  by  the  physician,  a  piece  of  membrane  hanging  down 
at  the  side.  As  the  symptoms  we  may  use  the  translation  of 
Adams :^  "A  sense  of  suffocation  accompanies  all  these  affections, 
and  they  can  by  no  means  swallow  with  freedom.  There  is  cough 
in  all  the  varieties,  but  especially  in  those  named  lorum  (a  broad, 
flat  strap)  and  fimbria  (the  border  or  edge;  this  is  the  variety  having 
a  club-shaped  end  to  it).  For  a  titillation  of  the  trachea  is  produced 
by  the  membrane,  and  in  some  cases  it  secretly  instils  some  liquid 
into  the  wind-pipe,  when  they  cough.  It  is  safe  to  apply  the  knife 
in  all  these  varieties;  but  in  the  uvula,  while  still  red,  hemorrhage, 
pains,  and  increase  of  inflammation  supervene."  In  the  chapter 
on  the  treatment  of  disease  around  the  uvula,  he  states  that  many 
of  them  require  surgical  treatment,  but  these  he  does  not  discuss, 
his  work  on  surgery  having  been  lost.  In  this  chapter  it  is  evident 
that  some  severe  faucial  inflammation,  accompanied  by  oedema  of 
the  u\ula  and  by  symptoms  of  dyspnoea,  many  of  the  cases  ending 
fatally,  were  familiar  to  Aretaeus.  We  can  only  conjecture  that 
some  of  these  were  diphtheria. 

Syphilis. — His  therapy  was  not  especially  different  from  that  of 
Celsus  in  such  cases,  but  at  the  end  of  this  chapter  on  the  therapy 
of  the  diseases  of  the  uvula,  occurs  a  sentence  which  to  me  is 
inexplicable  on  any  other  ground  than  that  of  the  existence  of 
syphilis,  or  again  of  some  disease  with  which  we  are  now  not 
familiar,  as  I  remarked  in  citing  a  similar  passage  from  the  Epi- 
demics of  Hippocrates.  In  this  sentence  of  Aretaeus  the  suggestive- 
ness,  to  my  mind,  is  still  more  striking.  We  may  translate  it  thus : 
"  But  should  the  part  become  purulent,  in  some,  the  bones  of  the 
palate  are  destroyed,  and  having  lingered  a  long  time  wasting 
away,  they  die."  Now  "consumption,"  as  x\dams  translates  it, 
does  not  produce  necrosis  of  the  palate  except  in  very  rare  cases, 
and  in  these  almost  never  beginning  as  a  primary  disease,  but 
rather  as  a  rare  incident  in  the  progress  of  general  tuberculosis. 
Personally  I  have  never  seen  a  case  of  necrosis  of  the  hard  palate 
caused  by  anything  but  syphilis,  though,  of  course,  as  before 
remarked,  we  must  keep  in  mind  the  rare  cases  of  scurvy  and 
phosphorus  poisoning. 

Kynanche  and  Synanche. — I  have  already  had  occasion  to  refer 
to  the  use  of  the  two  words  kynanche  and  synanche,  and  have 
quoted  Galen's  remark  that  the  difference  apparently  arose  from 
the  different  readings  of  the  initial  letter  of  the  word  by  the 
transcribers  of  the  Hippocratic  treatises.  Kynanche  (x'juayyr^)  is 
a  word  applied  to  the  choking  of  a  dog,  and  Aretaeus  makes  a 
part  of  his  clinical  picture  of  throat  inflammation  to  consist  of  the 
tongue  sticking  out  as  a  dog  does,  even  in  health.    It  must  be  borne 

1  Extant  Works.  Sydenham  ed.,  London,  1850,  p.  253.  Book  I,  On  the 
Causes  and  Sj^mptoms  of  Acute  Diseases.  Chap.  S,  on  the  Affections  about 
the  Uvula. 


72  CELSUS  AND   THE  P RE-GALENIC  WRITERS 

in  mind  that  Aretaeus  was  supposed  to  be  a  disciple  of  the  rhief 
exponent  of  the  Pneumatists,  Archigenes,  and  hence  we  find  him 
saying  that  he  beheved  synanche  to  be  a  disease  of  the  "pneuma" 
pure  and  simple,  and  he  applies  the  term  to  those  cases  in  which 
no  obstruction  is  visible,  or  to  those  in  which  the  inflammation 
has  also  descended  to  the  thorax,  but  whether  to  one  or  to  the 
other,  they  all  have  the  common  symptom  of  dyspnoea,  and  he 
adduces  the  significance  of  the  word,  not  as  Galen  suggests,  but 
from  the  collapse  of  the  parts  about  the  neck  and  chest.  Of  course, 
it  is  evident  here  again  that  there  is  a  misleading  classification  of 
throat  inflammation,  if  we  take  into  account  our  present  system, 
and  we  perceive  the  classification  of  Aretaeus  is  really  founded 
upon  the  situation  of  the  lesion  rather  than  its  nature.  That  some 
of  these  cases  were  also  diphtheria  admits  of  no  doubt,  but  in  the 
category  he  also  included  peritonsillitis  and  the  graver  forms  of 
phlegmonous  inflammation.  As  in  Celsus,  we  find  mention  made 
of  abscesses  in  these  cases  opening  here  and  there  around  the  ears 
externally,  and  it  again  becomes  evident  that  they  were  familiar 
with  more  cases  of  severe  and  deep  inflammation  around  the  fauces 
than  are  we. 

After  admiring  the  many  agreeable  prescriptions  recommended 
by  Aretaeus,  we  are  shocked  in  the  description  of  an  elegant  poul- 
tice scented  with  bay  leaves,  to  find  him  gravely  advising,  as  very 
efficacious  in  promoting  suppuration,  that  the  surface  shall  be 
sprinkled  with  the  finely  sifted  dung  of  pigeons  and  dogs;  but,  on 
the  whole,  the  treatment  of  the  simple  inflammatory  conditions 
by  local  applications  we  recognize  as  most  judicious.  When  it  is 
apparently  diphtheria,  or  other  obstructive  disease  of  the  larynx, 
Aretaeus  and  his  confreres  were  helpless,  and  recognized  the  malady 
as  deadly.  He  tried  to  bring  the  disease  outward  by  sweats  and 
counter-irritation. 

Laryngotomy. — In  this  place,  the  chapter  on  the  Therapeutics  of 
Synanche,^  occurs  the  much  quoted  passage  in  regard  to  laryngot- 
omy, which  I  would  translate  thus:  "But  those  who,  as  a  pre- 
caution against  suft'ocation  arising  from  synanche,  cut  the  trachea 
for  the  d^'spnoea,  do  not  seem  to  me  to  have  shown  by  the  attempt 
that  the  operation  is  warranted,  for  the  heat  of  the  inflammation 
becomes  greater  from  the  wound,  and  besides  increases  the  dyspnoea 
and  the  cough;  but  if  they  are  both  cartilaginous  and  unsuitable — " 
[Here  the  fragment  of  this  chapter  abruptly  ends.]  Now,  if  we 
remember  that  Aretaeus  supposed  that  the  dyspn(x\a  arose,  not 
from  obstructive  causes  as  we  understand  them,  l)ut  from  a  disease 
of  the  "  pneuma"  or  breath  itself,-  we  may  understand  how  irrational 

1  Extant  Works  (Adams),  p.  157-lGO;  trans,  p.  404-406. 

2  We  may  briefly  define  the  pneuma  as  conceived  by  the  ancients  to  be  that 
part  of  the  breath  which  contained  the  vital  energy,  but  it  would  lead  us  too 
far  astray  to  discuss  all  the  various  ramifications  and  forms  and  consec}uences 
of  this  idea,  so  necessary  in  some  shape  to  any  conception  of  the  mystery  we 
call  life. 


DIPHTHERIA  73 

a  procedure  the  opening  of  the  air  tube  seemed,  and  we  well  know 
that  in  the  worst  cases  which  were  the  ones  usually  reserved  for 
tracheotomy,  even  up  to  the  time  of  the  advent  of  intubation  in 
our  own  day,  the  results,  on  account  of  the  extension  of  the  trouble 
below  the  trachea,  fully  justified  Aretaeus'  skepticism.  We  have 
seen  that  Asclepiades  approved  of  the  operation,  and  we  shall 
find  Paulus  Aegineta,  several  centuries  later,  describing  the  opera- 
tion and  attributing  it  to  Antyllus. 

Diphtheria. — \Yhile,  as  we  have  seen,  there  is  abundant  evidence 
that  the  other  chapters  on  diseases  of  the  throat  include  reference 
to  cases  which  were  diphtheria,  there  is  a  special  chapter  devoted 
to  a  description  "Of  the  Ulcers  about  the  Tonsils,"^  in  which  the 
disease  is  unmistakable.  His  description  is  very  vivid,  but  as  to 
the  etiology  he  gropes  in  the  dark,  very  much  as  men  have  done 
in  all  ages  when  seeking  after  the  causes  of  phenomena.  He  says 
it  occurs  more  frequently  in  children  because  they  especially  draw 
in  deep  and  cold  breaths;  and  there  is  more  heat  in  them.  They 
are  greedy  and  hungry  and  their  desires  are  capricious.  They 
are  petulant  and  do  a  great  deal  of  bawling.  It  is  common  in 
girls  until  the  beginning  of  the  menses.  It  is  especially  common 
in  Egypt  and  Syria  on  account  of  their  diet  and  the  dryness  of 
the  air.  Hence  they  are  called  Egyptian  or  Syriac  ulcers.  We 
smile,  but  probably  no  more  contemptuously  than  future  historians 
will  at  our  own  ideas  of  etiology.  They  die  he  says  from  the  foulness 
of  the  odors — from  the  toxins  say  we.  In  his  symptomatology  we 
miss  only  one  characteristic,  and  that  is  the  coughing  up  and  the 
expectoration  of  the  membrane;  but  this  we  find  mentioned  by 
Galen.  His  treatment  included  the  use  of  escharotics  and  the 
cautery  for  the  so-called  ulcers.  Various  powders  of  an  astringent 
nature  were  to  be  blown  on  them  through  a  quill  or  a  tube.-  We 
hear  little  of  massage  and  exercise  from  Aretaeus;  this  therapeu- 
tic fad,  like  all  fads,  had  had  its  day  since  the  time  of  Asclepiades 
and  of  Celsus.  We  cannot  part  from  Aretaeus  without  quoting  his 
description  of  the  fatal  termination  of  cases  of  these  pestilential 
Syriac  ulcers: 

"The  manner  of  death  is  most  piteous;  pain  sharp  and  hot  as 
from  carbuncle;  respiration  bad,  for  their  breath  smells  strongly 
of  putrefaction,  as  they  constantly  inhale  the  same  again  into 
their  chest;  they  are  in  so  loathsome  a  state  that  they  cannot  endure 
the  smell  of  themselves;  countenance  pale  or  livid;  fever  acute; 
thirst  as  if  from  fire,  and  yet  they  do  not  desire  drink  for  fear  of 
the  pains  it  would  occasion;  for  they  become  sick  if  it  compress 

1  Adams  ed.,  p.  253. 

2  Heyiiiann  credits  Aretaeus  with  being  the  first  to  make  local  applications 
to  the  larynx  in  this  way,  but  it  is  found  frequently  mentioned  in  the  Hindu 
writings.  It  is  doul)tful,  however,  if  the  powder  ever  got  as  far  as  the  larj-nx. 
Without  modern  appliances  and  the  laryngoscope,  this  is  a  difficult  matter. 


74  CELSUS  AND   THE  PRE-GALENIC   WRITERS 

the  tonsils,  or  if  it  return  by  the  nostrils;  and  if  they  lie  down  they 
rise  up  again  as  not  ])eing  able  to  endure  the  recumbent  position; 
and,  if  they  rise  up,  they  are  forced  in  their  distress  to  lie  down 
again;  they  mostly  walk  about  erect,  for  in  their  inability  to  obtain 
relief  they  flee  from  rest,  as  if  wishing  to  dispel  one  pain  by  another. 
Inspiration  large,  as  desiring  cold  air  for  the  purpose  of  refrigeration, 
but  expiration  small,  for  the  ulceration,  as  if  produced  by  burning, 
is  inflamed  by  the  heat  of  the  respiration.  Hoarseness,  loss  of 
speech  su]:)er^'ene ;  and  these  symptoms  hurry  on  from  bad  to 
worse,  until  suddenly  falling  to  the  ground  they  expire."^ 

Rufus  of  Ephesus. — As  in  the  case  of  Aretaeus,  a  similar  uncer- 
tainty as  to  the  time  and  locality  in  which  Rufus  Ephesius  lived  is 
to  be  noted  in  history.  He  evidently  was  anterior  to  Galen,  who 
speaks  of  him  as  one  of  the  recent  writers,  while  he  does  not  refer  to 
Aretaeus  at  all,  who  must  have  flourished  about  the  same  time.  It 
is  said  that  lUifus  Ephesius  lived  during  the  reign  of  Trajan,  which 
began  in  98  a.d.  He  wrote  much  on  anatomical  subjects  and 
quoted  extensively^  from  the  works  of  others.  His  own  work,  or 
rather  such  of  it  as  has  remained  to  us,  is  of  little  value.  I  have  ex- 
tracted from  it  the  following  notices  which  pertain  to  our  subject. 
He  speaks  of  the  tonsils'^  as  four  in  number,  two  on  each  side  of 
the  pharynx  (aajixcodrj  yjii  ao£vocfr>>^),  fleshy  and  gland-like.  We  note 
thus  early  the  occurrence  of  the  word  "adenoid"  applied  to  the 
structure  of  this  tissue.  Again,  in  the  "Anatomy  of  the  Parts  of 
the  Body,"  ascribed  to  the  same  author,  occurs  the  following: 
"At  the  deepest  portion  of  the  tongue  and  at  each  side  of  this 
organ  are  arranged  at  its  base  excrescences  called  lateral  glands  of 
the  isthmus  to  the  number  of  six;  they  have  a  gland-like  structure. 
The  form  is  rounded.  They  are  movable  and  easy  to  excise;  they 
are  attached  by  means  of  small  membranes  which  hold  them 
at  the  base.  Four  are  to  be  seen  at  each  side  of  the  l)ottom  of  the 
mouth — two  are  less  visible."  We  may  conjecture  there  lias  here 
been  some  mutilation  of  the  text.  He  noted  they  are  more  promi- 
nent when  inflamed.  He  recognizes  that  the  uvula  is  of  little  use 
and  its  amputation  produces  no  alteration  of  function.  As  we 
shall  see,  in  the  descrij)ti()n  of  the  tonsils  he  is  less  accurate  than 
Galen,  but  more  in  accord  with  modern  teaching  as  to  the  uvula. 
Rhazes,  an  Arabian  writer,  quotes  Rufus  as  saying:  "In  fracture 
of  the  nose  it  is  well  to  fill  the  nostril  completely  with  cotton  (or 
silk)  stuff,  and  not  extract  it  until  the  nose  has  taken  its  shape. "^ 

Tracheotomy  of  Antyllus. — Here  is,  perhaps,  the  place  to  introduce 
a  quotation  l)y  i'aulus  Aegineta  from  the  lost  works  of  Antyllus, 
a  surgeon  of  much  note,  who  is  said  to  have  lived  during  the  reign 
of  Hadrian  (117-138  a.d.).     It  is  the  first  specific  description  of 

'  I  have  hou-e  used  the  excellent  translation  of  Adams,  p.  255. 
2(Euvi-es  de  Rufus  d'Ephese,  Paris,  1879,  p.  141. 
'  Ibid.,  p.  471. 


COELIUS  AURELIANUS  75 

the  technique  of  the  operation  of  tracheotomy.  I  avail  myself  of 
the  Sydenham  translation  of  Adams. ^  "  The  most  famous  surgeons 
have  also  described  this  operation  (laryngotomy) .  Antyllus, 
therefore,  says,  'In  cases  of  cynanche  (as  we  will  explain  under 
the  head  of  Dietetics)  we  entirely  disapprove  of  this  operation, 
because  the  incision  is  wholly  unavailing  when  all  the  arteries 
(the  whole  of  the  trachea  and  bronchi)  and  the  lungs  are  affected; 
but  in  inflammations  about  the  mouth  and  palate  and  in  cases  of 
indurated  tonsils,  which  obstruct  the  mouth  of  the  wind-pipe  as 
the  trachea  is  unafl'ected,  it  will  be  proper  to  have  recourse  to 
pharyngotomy,  in  order  to  avoid  the  risk  of  suffocation.  When, 
therefore,  we  engage  in  the  operation  we  slit  open  a  part  of  the 
arteria  aspera  (for  it  is  dangerous  to  divide  the  whole)  below  the 
top  of  the  wind-pipe,  about  the  third  or  fourth  ring.  For  this  is  a 
convenient  situation,  as  being  free  of  flesh,  and  because  the  vessels 
are  placed  at  a  distance  from  the  part  which  is  divided.  Where- 
fore bending  the  patient's  head  backward,  so  as  to  bring  the  wind- 
pipe better  into  view,  we  are  to  make  a  transverse  incision  between 
two  of  the  rings,  so  that  it  may  not  be  the  cartilage  which  is 
divided,  but  the  membrane  connecting  the  cartilages.  If  one  be 
more  timid  in  operating,  one  may  first  stretch  the  skin  with  a 
hook  and  divide  it,  and  then  removing  the  vessels  aside,  if  they 
come  in  the  way,  make  the  incision.'  These  are  the  words  of 
Antyllus."  Xow,  by  the  phrase  in  parentheses,  "for  it  is  dangerous 
to  divide  the  whole,"  we  are  reminded  of  the  passages  I  have  cited 
from  the  Talmud  and  the  Rig  Veda.  We  may,  therefore,  entertain 
some  conception  of  the  antiquity  of  the  operation  of  tracheotoni}-, 
though  it  is  not  mentioned  in  Pliny. 

Coelius  Aurelianus. — Coelius  Aurelianus  is  another  of  the  many 
medical  writers  whose  epoch  we  cannot  definitely  ascertain,  though 
it  is  supposed  he  was  a  contemporary  of  Aretaeus  and  of  Galen. 
His  barbarous  Latin  and  his  ignorance  of  Greek  show  that  his 
knowledge  of  polite  literature  was  limited,  but  his  accurate  descrip- 
tion of  disease,  and  especially  his  copious  citations  of  earlier  writers 
whose  books  have  perished,  make  his  works  important  in  the 
history  of  medicine.  He  describes  very  vi^•idly  the  symptoms  of 
acute  throat  inflammation,-  which  he  calls  synanche,  and  he 
includes  under  this  head  everything  of  the  kind.  His  treatment 
does  not  differ  materially  from  that  of  Aretaeus.  He  was  very  fond 
of  the  use  of  oil  both  as  a  menstruum  for  gargles  and  for  the  inunc- 
tion of  the  whole  body,  when  he  used  it  warm  in  se\'ere  cases.  He 
disapproved  of  the  practice  recommended  by  Hippocrates  and 
his  followers,  of  bleeding  from  the  veins  beneath  the  tongue  in 
synanche,  saying  it  did  harm  rather  than  good.  He  notes  Hippoc- 
rates' suggestion  of  passing  a  tube  along  the  tongue  into  the  pharynx 

1  The  Seven  Books  of  Paiihis  Aejiineta  (Adams),  LoikIoii,  1S4G-47,  II,  p.  301 
-  De  Morbis  Acutis,  Lib.  Ill,  Cap.  I,  II,  III,  IV  (Aiiunan  ed.),  p.  179-198. 


76  GALEN 

(or  larynx?)  for  the  relief  of  dyspnoea.  He  strongly  condemned 
the  practice  which  he  says  Asclepiades  falsely  ascribed  to  the 
older  writers  of  opening  the  trachea.  He  says  the  report  is  an 
invention  of  Asclepiades,  that  it  is  rash  and  dangerous,  and  it 
would  be  a  crime  to  perform  it.^  Nevertheless,  we  have  seen  that 
Antyllus,  who  must  have  lived  about  the  same  time,  carefully 
describing  it,  according  to  Paulus  Aegineta.  Aurelianus  has  a 
chapter  on  hoarseness-  arising  from  colds  and  shouting,  and  notices 
the  diseased  uvula  as  the  cause  of  chronic  coughs;  he  has  also  a 
chapter  on  coryza.^ 

GALEN. 

Gibbon  begins  his  immortal  work,  "The  Decline  and  Fall  of  the 
Roman  Empire,"  with  the  sentence:  "In  the  second  century  of 
the  Christian  era  the  Empire  of  Rome  comprehended  the  fairest 
part  of  the  earth  and  the  most  civilized  portion  of  mankind.  .  .  . 
If  a  man  w^ere  called  to  fix  the  period  in  the  history  of  the  world 
during  which  the  condition  of  the  human  race  was  most  happy 
and  prosperous,  he  would,  without  hesitation,  name  that  which 
elapsed  from  the  death  of  Domitian  (96  a.d.)  to  the  accession  of 
Commodus"  (180  a.d.).  It  was  in  this  epoch,  at  the  culmination 
of  the  mightiest  empire  that  the  world  has  ever  seen,  that  Claudius 
Galen  lived.  It  was  under  Trajan  (98-117  a.d.)  the  empire  reached 
its  greatest  territorial  extent,^  and  in  the  following  reign  of  Hadrian 
(131  A.D.)  Galen  was  born.  With  many  vicissitudes  of  favor  and 
exile  he  practised  at  Rome  and  elsewhere.  His  early  life  was  passed 
under  the  beneficent  reign  of  Antoninus  Pius,  and  that  of  the  great 
jNIarcus  Aurelius,  whose  friendship  he  is  said  to  have  enjoyed;  but 
in  his  last  days  he  must  have  witnessed  the  disgraceful  scenes 
which  marked  the  reign  of  the  brutal  and  licentious  gladiator 
Commodus,  to  whom  he  was  physician  in  ordinary,  and  those  of 
his  impotent  and  infamous  successors,  when  mighty  Rome  had 
already  begun  to  totter  toward  the  long-delayed  collapse  of  its 
widespread  power.  Hence  it  is  that  after  Galen  we  are  to  meet 
no  great  work  in  medicine,  which  marks  its  material  progress, 
for  more  than  a  thousand  years.  So  intimately  are  all  the  forces 
of  civilization  interrelated  and  interdejjendent  that  the  history  of 
no  one  division  can  be  intelligently  followed  without  the  side-light 
which  other  parts  throw  upon  it. 

We  see  in  Galen  the  culmination  of  the  medical  progress  of  the 
ancient  world,  and  in  the  light  he  transmitted  the  new  world,  when 

1  Dc  Morbis  Acutis,  Lib.  Ill,  Cap.  IV.  • 

*  De  Morbis  Chronicis,  Lib.  II,  Cap.  VI  (Amman  ed.),  P-  378. 

3  De  IMorbis  Chronicis.  Lib.  11,  Cap.  VII,  VIII,  p.  ;i79-388  For  a  more 
complete  review  of  the  work  of  CocUus  Aurehanus,  especially  in  regard  to  diph- 
theria and  angina,  vid.  Mlinch.  med.  Woch.,  1899,  XLVI,  p.  1382. 

.^Freeman:     Chief  Periods  of  European  History. 


THE  ANATOMY  OF  GALEN  77 

it  first  began  to  emerge  from  the  chaos  of  Rome's  destruction, 
made  its  first  feeble  move  toward  a  renewed  growth  in  the  develop- 
ment of  medical  knowledge.^  I  have  several  times  had  occasion 
to  anticipate  in  this  history  the  account  of  some  of  Galen's  views, 
and  it  is  not  necessary  here  to  review  these.  I  have  also  had 
occasion  to  animadvert  upon  the  great  advance  of  the  anatomical 
knowledge  of  the  upper  air  passages  displayed  in  the  works  of 
Galen,  beyond  that  to  be  found  in  the  works  of  his  predecessors. 
It  needs  very  little  perusal  of  them  to  convince  one  of  the  enormous 
strides  made  in  the  anatomy  of  the  human  body  since  the  days 
of  Hippocrates,  five  or  six  hundred  years  earlier.  From  Celsus, 
one  hundred  years  his  senior,  and  from  Aretaeus,  perhaps  his  con- 
temporary, we  can  derive  only  slight  information  as  to  the  ana- 
tomical and  physiological  knowledge  they  possessed.  They  were 
evidently  men  of  commanding  talent,  but  their  works  which  have 
been  preserved  are  too  meager  for  us  to  form  much  of  an  idea  of 
their  fundamental  knowledge  of  the  human  body  and  its  functions. 
The  An'atomy  of  Galen. — It  is  in  Galen's  writings,  therefore,  that 
we  first  gain  an  idea  of  the  advance  made  in  those  departments 
of  medicine  by  the  Alexandrian  School  of  Anatomists.  It  is  signi- 
ficant of  the  influence  exerted  by  the  great  libraries  of  Pergamos 
and  Alexandria  that  the  birth  and  early  education  of  Galen  are 
accredited  to  the  former  city,  and  that  he  acquired  at  least  some 
of  his  knowledge  in  the  latter.-  It  would  have  been  manifestly 
impossible  for  any  one  man  to  have  himself  originated  the  discovery 
of  one-tenth  part  of  the  new  anatomical  facts  we  meet  with  in 
Galen  for  the  first  time,  although  he  doubtless  is  the  real  author 
of  some  of  them,  especially  of  those  in  regard  to  the  larynx.  Far 
inferior  to  the  author  of  the  best  of  the  Hippocratic  treatises  in 
talent  and  in  genius,  but  greatly  surpassing  him  in  accurate  knowl- 
edge, Galen  is  contentious,  prosaic,  and  tiresome  to  the  last  degree. 
I  would  recommend  that  those  who  love  to  indulge  in  medical 
polemics  should,  as  a  punishment  to  fit  the  crime,  be  compelled 
to  read  seriatim  the  extant  works  of  Claudius  Galen.  It  is,  however, 
to  these  very  personal  qualities  we  are  indebted  apparently,  not 
only  for  all  the  medical  learning  of  his  o^^'n  times,  but  for  very 

1  It  is  true  that  for  seven  hundred  j-cars  his  works  were  not  read  in  Eiu'ope, 
but  after  Gregory  destroyed  the  hbrary  on  tlie  Cai)itohne,  that  might  be  said 
of  every  other  medical  writer  of  merit.  Under  the  Eastern  Empire,  during 
this  time  he  was  confessedly  or  secretly,  with  Pliny,  the  origin  of  all  medical 
knowledge,  but  the  first  translations  of  Galen  from  Greek  into  Arabic,  and 
hence  into  Latin,  are  in  the  eleventh  and  twelfth  centiu-ies,  while  direct  trans- 
lations from  Greek  to  Latin  did  not  take  ])lace  imtil  the  fourteenth  centur.y. 

2  If ,  as  it  appears  probable,  Galen  was  not  acquainted  with  the  dissection 
of  the  human  b(^y,  it  would  seem  to  follow  that  the  jjractice  of  the  Alexandrian 
School  in  the  time  of  Erasistratus  and  Horophilus  had  not  persisted  to  the 
time  of  (jalen.  This  cessation,  if  it  really  took  place,  we  maj'  conjecture  to 
have  been  due  to  the  prevalence  of  indigenous  I'-gyptian  prejudice  over  the 
tendencies  of  Greek  science. 


78  GALEN 

much  Avliich  we  possess  of  that  which  existed  before  his  ])irth  in 
the  works  of  eariier  writers.  This  it  is  which  has  raised  tlic  medical 
works  of  Galen  above  all  others  in  importance  to  medical  science, 
greater  even  than  those  of  the  school  of  Cos.  Had  the  latter  not 
come  down  to  us  in  their  own  form,  we  would  still  have  most  of 
them  reproduced  either  literally  or  in  substance  by  (lalen. 

The  Intermaxillary. — (lalen  described  an  intermaxillary  bone^ 
in  man.  This  a{)parent  mistake  was  probably  due  to  his  observa- 
tions on  the  skeletons  of  animals  which  he  seems  to  have  dissected 
much  more  frequently  than  man.  It  led  many  hundreds  of  years 
afterward  to  a  warm  discussion  between  anatomists.  Finally, 
in  the  last  century,  Vicq  D'Azir  and  Goethe  definitely  settled 
the  matter  by  showino;  that  traces  of  this  intermaxillary  bone  are 
found  in  the  skulls  of  children  and  in  the  fetus.  This  was  one  of 
the  forerunners  of  Darwinism,  a  discovery  of  one  of  the  suggestive 
facts  which,  with  Goethe's  INIetamorphosis  of  Plants,  formed  the 
germ  of  tlie  doctrine  of  Evolution  in  the  animal  and  vegetable 
world,  and  of  the  Spencerian  philosophy.  It  is  a  striking  instance 
of  the  Spencerian  philosophy.  It  is  a  striking  instance  of  the 
necessity  of  a  proper  soil  for  the  germination  of  any  observation  of 
nature.  Had  the  old  Greek  and  Roman  civilization  persisted  a 
few  centuries  more  who  can  doubt  that  the  circulation  of  the  blood- 
would  have  been  known  a  thousand  years  earlier,  or  that  the 
enlightenment  which  has  followed  the  promulgation  of  the  doctrine 
of  Evolution  would  have  been  similarly  antedated.  Galen  fully 
recognizes  the  nose  as  the  beginning  of  the  respiratory  tract.^ 
He  describes  the  muscles*  of  the  external  nose  as  two  in  number, 
one  on  each  side,  for  the  dilatation  of  the  nostrils,  and  he  understood 
the  distribution  of  the  facial  or  hard  part  of  the  seventh  pair  of 
nerves  to  them.'^ 

Nasal  Anatomy. — Galen's  description  of  the  internal  nose  in  the 
"De  Instrumento  Odoratus""^  reads  as  follows:  "The  nose  having 
a  median  dividing  wall  has  two  conspicuous  openings,  one  for 
each  nostril,  and  each  one  of  them  is  divided  in  the  upper  part 
into  two  portions.  One  of  these  divisions  leads  to  the  mouth  and 
the  other  one  upward  so  that  it  starts  from  the  entrance  and  ascends 
to  the  brain  itself.  There  are  two  hollow  oblong  ofl'shoots  of 
these  (it?)  toward  it   (these ?),^  having  their  beginning  from  the 

1  De  Usu  Partium,  XI,  Cap.  XX. 

2  After  a  careful  perusal  of  much  of  the  writings  of  Galen  1  am  unable  to 
grasp  thoroughly  the  idea  he  had  of  the  circulation. 

'  De  Usu  Partium,  Xl-II.    I  make  use  chiefly  of  Ki'ilm's  edition. 

^  De  Dissect ione  Musculorum. 

5  De  Usu  Partium,  Lib.  XVI,  .3.  '  Kuhn,  II,  p.  858. 

'  Kiihn's  Greek  text,  from  which  I  translate,  docs  not  seem  to  me  to  warrant 
the  Latin  construction  which  accomiianies  it.  Neither  the  text  nor  the  trans- 
lation of  Kiihn  are  here  felicitous.  We  must  imagine  that  the  text  itself  has 
been  mutilated  by  ignorant  and  careless  copyists,  but  Kiihn's  translation  in 
making  use  of  an  unwairanted  construction  docs  not  thereby  elucidate  the 
anatomical  description. 


THE  FUNCTIONS  OF  THE  NOSE  79 

anterior  ca\'ities,  reaching  to  that  part  of  the  skull  where  the  nose 
has  its  origin.  At  this  point  is  the  situation  of  the  sieve-like  bones 
(ethmoid),  the  function  of  which  the  name  indicates,  and  the 
thick  membrane  (the  dura  mater)  with  which  that  of  the  bones 
is  continuous,  is  pierced  by  fine  openings.  Through  these  first 
the  thicker  parts  of  the  excretions  from  the  brain  are  transmitted 
(the  custom  was  started  by  Aristotle  of  calling  such  things  excre- 
tions), for  things  more  vaporous  mount  to  the  sutures  and  escape 
from  it.  The  thick  part  of  these,  such  as  phlegm  in  coryza,  is 
carried  downward,  having  first  passed  through  the  dura  mater. 
After  having  been  strained  through  the  sie^'e-like  bones,  it  thus 
passes  into  the  channels  of  the  nose.  There  is  a  part  runs  into  the 
openings  of  those  channels  heretofore  mentioned  which  lead  into 
the  mouth  itself;  and  the  mucus,  especially  such  as  is  viscid,  part 
of  it  falling  at  one  end  into  the  channels  leading  into  the  mouth, 
the  other  part  into  the  passages  on  both  sides  which  lead  outwardly, 
is  blown  forcibly  from  the  nostrils  and  is  hawked  out  through  the 
mouth.  A  bloodless  (sic)  membrane,  thicker  than  the  skin,  lines 
those  straight  passages  of  the  nose  leading  up  to  the  sieve-like 
bones,  and  likewise  those  other  oblique  channels  which  I  have  said 
end  in  the  mouth.  This  membrane  is  continuous  with  that  lining 
the  circumference  of  the  whole  mouth,  and  covering  the  tongue, 
and  in  addition  to  these  the  pharynx,  the  larynx,  the  trachea,  and 
the  esophagus.  To  this  membrane,  which  is  one  from  the  beginning 
and  continuous,  and  in  all  the  parts  mentioned,  has  the  appearance 
of  the  same  substance,  but  has  not  the  same  thickness  in  all  parts, 
certain  small  nerves  are  distributed,  springing  from  the  brain, 
except  those  to  the  tongue."  This  idea  of  the  brain  as  the  origin 
of  the  secretions  of  the  mucous  membranes  of  the  respiratory  and 
digestive  tracts,  as  has  been  said,  was  due  to  the  ignorance  of  the 
existence  of  the  muciparous  glands  and  to  the  absolute  mental 
necessity  of  finding  some  explanation  for  the  presence  of  the  mucus. 
As  we  have  seen,  the  idea  is  found  in  the  Hippocratic  writings, 
and  it  persisted  for  two  thousand  years  in  medical  belief.  The 
eyes  and  ears  were  also  supposed  to  void  their  secretions  through 
the  lacrimal  sac  and  the  Eustachian  tubes  into  the  nose.  He 
describes  the  trigeminus  nerve^  as  sending  filaments  to  the  mucous 
membrane  of  the  nose  and  palate. 

The  Functions  of  the  Nose. — In  order  to  show  how  closely,  in 
spite  of  the  gross  errors  as  to  the  internal  anatomy  of  the  nose, 
Galen's  physiology  corresponded  with  what  is  orthodox  doctrine 
in  laryngology  to-day,  I  quote  from  another  work  of  (ialen.- 
Although  the  first  sentence  or  two  has  now  become  obsolete,  the 
rest  seems  as  though  it  might  have  been  taken  from  a  modern 

1  De  Usu  Partium,  IX,  15.    Lib.  IX,  Cap.  XV,  (Klihn)  III,  p.  743. 

2  Ibid.     Lib.  XI,  Cap.  XL  (Kiihn)  III,  p.  886. 


80  GALEN 

text-book  of  the  nose  and  throat:  "  It  has  been  said  conrernino;  the 
uvula,  in  the  commentary  concerning  the  voice,  that  it  contributes 
to  the  strength  and  beauty  of  the  hitter,  and  both  in  an  admirable 
manner,  since  the  entering  air  first  is  divided  by  it  and  the  force 
of  its  current  is  broken,  and  thereby  that  of  its  frigidity,  so 
that  some  of  those  who  amputate  it  at  its  base  not  only  clearly 
injure  the  voice,  but  the  increased  coldness  of  the  inspiration 
is  felt,  and  many  breathing  this  into  the  lungs  and  the  thorax  are 
thereby  killed,  so  that  it  is  not  right  to  cut  it  off  rashly,  nor  as 
chance  would  have  it,  but  to  leave  some  part  of  it  at  the  base." 
"  It  has  been  stated  before  in  regard  to  the  perforations  within 
the  nostrils,  how  wonderfully  the  ])one  situated  in  front  of  the 
ventricles  of  the  brain  receives  them,  being  similar  to  a  sponge,  and 
in  regard  to  the  passage  of  these  into  the  mouth,  which  is  in  the 
palate,  how  it  is  arranged  that  the  beginning  of  the  inspiration  is 
not  directly  into  the  trachea,  but  there  is  a  certain  deflection  of 
it,  as  a  curve,  before  the  breath  arrives  in  the  trachea,  which 
arrangement  it  seems  to  me  has  a  twofold  advantage :  first,  because 
the  air  surrounding  us  is  at  times  quite  cold  and  the  lungs  then 
would  be  chilled;  and,  secondly,  because  small  particles  of  dust  or 
of  ashes  or  anything  of  this  kind  may  not  fall  into  the  trachea.  In 
this  bend,  indeed,  the  breath  may  be  carried  further,  but  small 
particles  of  this  kind  are  arrested  so  that  they  first,  at  this  turn, 
fall  upon  soft  and  wet  surfaces  which  are  somewhat  mucilaginous 
and  are  thus  able  to  retain  those  which  fall.  If  any  get  as  far  as 
the  mouth,  they  stick  to  the  palate  and  uvula.  An  exemplification 
of  this  is  what  daily  happens  to  those  who  wrestle  in  much  dust, 
as  well  as  to  those  who  are  on  a  dustv  lournev.  In  a  little  while 
they  blow  dust  from  their  nostrils  or  si)it  it  out;  but  unless  the 
channels  of  the  nostrils  were  first  directed  straight  up  in  the  head, 
and  thence  obliquely  backward  to  the  palate,  and  unless  the  uvula 
were  there,  it  is  evident  that  nothing  would  prevent  everything 
falling  into  the  trachea,  for  this  sometimes  happens  when  one 
breathes  by  the  mouth.  I  have  even  seen  many  athletes  beaten 
in  this  very  way,  because  the  dust  being  breathed  in  by  the  mouth, 
they  are  nearly  suffocated.  When,  indeed,  any  inflammation  or 
tumor  is  present  or  any  other  affection  obstructing  the  nose,  then 
they  are  compelled  to  breathe  through  the  mouth;  from  which 
thing  it  is  possible  to  know  that  the  nose  is  first  in  order  as  an 
organ  of  respiration,  while  the  mouth,  if  nothing  affects  the  animal, 
is  in  no  way  the  organ  of  resj)iration,  but  in  certain  cases  mentioned 
is  an  aid  to  respiration,  which  all  directly  points  to  the  fact,  which 
I  have  urged  at  the  beginning  of  every  disciuisition,  that  our  INIaker 
formed  all  these  things  with  one  end  of  Ilis  work  in  view." 

The  Voice. — Galen's  book  upon  "The  Formation  of  the  Voice" 
has  been  lost.  Doubtless,  had  this  been  preserved,  we  would 
ha\'e  been  al)le  to  find  much  of  interest  in  it.     As  it  is,  we  read 


THE  VOICE  81 

much  concerning  the  external  muscles  of  the  neck,'^  and  we  learn 
that  he  distinguished  twelve  intralaryngeal  muscles,  i.  e.,  six 
pairs.^  He  described  the  cartilages  of  the  larynx  as  three  in  number, 
the  thyroid,  the  cricoid,  and  the  arytenoid.  He  supposed  the 
latter  was  a  single  cartilage.  We  have  seen  how  Aristotle  described 
the  anatomy  of  the  trachea.  For  him  it  was  made  up  of  entire 
cartilaginous  rings  superimposed  one  on  the  other;  but  Galen  knew 
better,  describing  the  membranous  portion  behind  and  recognizing 
its  function^  of  facilitating  deglutition.^ 

He  is  somewhat  confused  in  his  description  of  the  production 
of  the  voice,  at  least  in  the  books  which  have  remained  to  us;  but 
it  seems  as  near  as  possible  to  the  proper  explanation  in  an  age 
when  the  vibratory  movements  of  the  air  as  well  as  its  other  physical 
properties  were  so  imperfectly  understood.  He  claims  to  have 
been  the  first  to  discover  and  describe  the  ventricles  of  the  larvnx, 
and  he  well  imderstood  that  the  glottis  was  the  point  at  which 
the  voice  was  produced,  likening  it  to  an  ancient  flute.  He  describes 
the  vocal  cords  as  a  membranous  substance  so  constituted  as  to 
resist  the  impact  of  the  air  and  lubricated  by  mucus  to  prevent 
injury  from  the  vibrations  of  a  dry  surface.^  "For  it  is  pointed 
out  there  ("The  Formation  of  the  Voice")  both  that  the  trachea 
prepares  and  prearranges  the  voice  for  the  larynx,  and  it  being 
arrived  there,  the}'  (the  cartilages)  increase  it,  and  it  is  still  further 
augmented  by  the  vault  of  the  throat  which  acts  like  a  sounding 
board,  the  palate  like  a  plectrum." '^ 

He  reproves  those  who  think  the  voice  is  sent  forth  by  the  heart, 
but  declares  that  the  larynx  is  the  instrument  of  the  voice.^  He 
corrects  Erasistratus^  for  saying  that  the  pulmonary  vein,  like 
the  bronchi,  is  free  of  blood;  the  latter,  he  says,  contains  blood 
only  when  there  is  a  tear,  or  an  anastomosis  with  a  bloodvessel, 
when  it  mounts  to  the  pharynx  and  is  voided. 

We  have  seen  that  Galen,  in  a  very  qualified  manner,  was  inclined 
to  share  the  belief  of  his  predecessors  that  fluids  when  swallowed 
passed  at  least  to  some  extent  into  the  lungs,  and  he  seems  to  have 
believed  that  it  is  possible,  by  allowing  medicaments  to  slowly 
melt  in  the  mouth  and  by  restraining  the  inclination  to  cough, 
for  some  of  the  material  to  find  its  wav  into  the  lar\'nx  and  thus 
benefit  those  suffering  from  affections  of  that  organ,  which  he 
often  noted  in  actors,  singers,  etc.'^    The  drugs  he  commended  for 

1  De  Usu  Partium.   Lib.  VII,  Cap.  XVII  et  seq.,  (Kiihn)  III,  p.  588. 

2  De  Musculorum  Dissectione,  XMII,  pars  2,  p.  92G. 
'  De  Usu  Partium,  XII,  3,  (Kiihii)  IV,  p.  6. 

^  De  Musculorum  Dissectione,  (Kiihn)  XVIII,  pars  2,  p.  926. 
5De  Usu  Partium.  VII,  13,  (Kiihn)  III,  p.  oGO. 
«  Ibid.   Lib.  VII,  Cap.  V,  (Kiihn)  III,  p.  525. 

"  Placitis  Platon.  et  Hippocratis.   Lib.  II,  Cap.  V,  (Kiihn)  V,  p.  240. 
8De  Usu  Partium.   Lib.  VII,  Cap.  Ill,  (Kiihn)  III,  p.  518. 
'De  Compositione  Medicament,  (Kiihn)  XIII. 
6 


82  GALEN 

these  troches  are  miuli  the  same  as  we  use  today.  This  was  a 
favorite  method  of  medication  with  Asclepiades.  Perhaps  it  was 
for  this  reason  that  Galen  declared  that  ulcers  of  the  wind-pipe 
are  easily  cured.  His  explanation  of  speech  was  couched  in  almost 
the  same  words  as  that  of  Aristotle,  saying  that  the  voice  produces 
vowels  and  the  tongue,  nares,  lips  and  teeth  form  the  consonants.^ 

The  Glands. — He  seems  to  have  appreciated  the  identity  of  the 
lymph  glands  in  the  neck  with  those  of  other  localities,  for  he  says: 
"There  are  around  the  pharynx  and  larynx  certain  glands  similar 
to  those  in  the  mesentery,  but  these  latter  are  small,  and  on  this 
account  are  not  commonly  recognized,  but  those  around  the  fauces 
and  larynx  arc  large  and  prominent."-  This,  of  course,  could 
only  have  been  learned  by  careful  dissection,  and  from  the  context 
we  may  imagine  that  he  confused  pathological  with  physiological 
conditions. 

Galen^  quotes  INIarinus  as  saying:  "The  use  of  all  the  glands 
is  twofold;  (1)  for  they  either  support  the  deep  vessels  which  are 
accustomed  to  be  suddenly  swelled  (?)  and  undergo  the  dangers 
of  divulsion  on  account  of  more  rapid  movements;  (2)  or  they  are 
able  to  moisten  by  the  generation  of  humors  the  parts  which  are 
in  need  of  viscid  and  widespread  lubrication,  lest  easily  becoming 
dry  they  may  be  unfit  for  motion.  (And  as  for  the  other  kind  of 
glands  which  reinforce  the  vessels  whose  function  it  is  to  open  (?), 
we  will  leave  that  for  the  time,  as  we  have  no  use  for  it  in  this 
place.)" 

Elsewhere  Galen'*  explains  "that  since  the  glands,  which  fill 
what  space  there  is  in  the  midst  of  vessels  distributed  to  various 
parts,  act  as  a  foundation  or  support  for  this  distrilnition,  they  are 
of  no  very  great  use  to  living  beings,  but  nature  out  of  its  abound- 
ing provision  has  formed  these  glands  as  it  has  many  other  things." 

Galen's^  reference  to  glands  around  the  larynx  and  pharynx 
similar  to  those  of  the  mesentery,  may  mean  the  thyroid  and  the 
tonsils.  He  refers  in  the  same  manner  here  to  glands  as  elsewhere. 
This,  quoted  by  jNIorgagni,*^  I  am  unable  to  find  in  Kiihn's  Galen. 
Galen,  or  whoever  is  the  author  of  the  book,  "  De  Voce  et  Anhelitu," 
says:  "The  neck,  however,  has  two  glands  in  which  humidity  is 
generated.  But  from  these  two  glands  which  are  in  the  neck  veins 
are  not  given  off  in  which  the  humor  runs  as  in  those  which  come 
from  the  glands  of  the  tongue."     Evidently  the  thyroid  gland. 

The  Recurrent  Nerves. — He  vaunts  his  discoveries  in  the  larynx 
thus:    "Attend,  therefore,  especially  to  this  exposition  which  I 

1  De  Locis  Affectis.     Lib.  IV,  Cap.  IX,  (Kfihn)  VIII,  p.  2(56. 

2  De  Aliment  Facultat.    Lib.  Ill,  Cap.  VI,  (Kiihn)  VI,  p.  673. 

3  De  Semine.     Lib.  II,  (Kuhn)  II,  p.  594. 

*  De  Methodo  Medcndi.     Lib.  XIV,  Cap.  XI,  (Kiihn)  X,  p.  982. 

^  De  Aliment orum  Facultatibus.    Lib.  Ill,  Cap.  VI,  (Kiihn)  VI,  p.  673. 

'  Morgagni:     Adversaria  Anatom,  I,  26. 


THE  RECURRENT  NERVES  83 

have  in  hand,  because  I  was  the  first  to  discover  it.  None  of  the 
anatomists  have  hitherto  known  anything  of  these  nerves  (the 
recurrents),  nor  of  those  things  hitherto  mentioned  concerning  the 
structure  of  the  larynx.  Therefore,  having  turned  your  attention 
to  that  which  is  most  to  be  respected,  and  having  become  a  pupil 
worthy  of  the  instruction  about  to  be  imparted,  listen  to  the 
exposition  setting  forth  a  most  wonderful  phenomenon  of  nature."^ 
This  wonderful  arrangement  was  the  reflection  of  the  recurrent 
laryngeal  nerves  around  the  vessels  of  the  thorax;  but  when  he 
proceeds  to  explain  it  on  the  principle  of  the  pulley,  so  that  they 
may  approach  the  laryngeal  muscles  from  below,  his  solemnity  and 
impressiveness  in  preparing  the  wondering  pupils  for  the  great 
secret  seems  a  trifle  ludicrous  to  modern  readers.  However,  no 
one  has  really  ever  succeeded  any  better  in  attempting  to  explain 
this  anatomical  phenomenon,  though  there  have  been  many  theories 
advanced  since  "the  days  of  Galen. 

Elsewhere^  he  again  claims  that  he  was  the  first  to  discover  and 
give  a  name  to  the  recurrent  nerves,  those  only  being  known  to 
his  preceptors  which  were  near  the  arteries  (pneumogastrics).  In 
several  places  he  makes  the  statement  that  chilling  of  the  recurrent 
nerves  during  operations  damages  the  voice,  and  he,  therefore, 
advised  against  operations  in  this  region  during  cold  weather.  He 
relates  the  case  of  a  boy  who  was  operated  on  for  a  struma,  which 
was  removed  by  evulsion,  causing  aphonia,  due  to  injury  of  the 
recurrent  nerves.  In  this  connection  it  may  be  well  to  mention  a 
belief  of  the  old  Greek  philosophers,  the  origin  of  which  Galen,  in 
confuting  with  much  prolixity,  ascribes  to  Zeno  the  Stoic,  it 
having  been  transmitted  by  Diogenes  Babylonius  and  subsequently 
taught  by  Chrysippus.^  Cicero^  expresses  it  thus:  "The  trachea 
reaches  from  the  lungs  to  the  back  part  of  the  mouth  through  which 
the  voice,  taking  its  beginning  from  the  mind,  is  perceived  and 
has  its  origin."  Galen  savs  the  Stoics  reasoned  thus :  "  It  is  evident 
the  voice  cometh  from  the  mind.  It  is  also  evident  it  cometh  from 
the  larynx.  Hence  the  mind  is  not  in  the  brain."  Galen  demolished 
this  sophism  thus:  "They  will  wonder  when  they  hear  the  voice 
is  produced  from  the  brain,  and  much  more  after  having  heard 
that  all  voluntary  motion  is  performed  by  the  muscles.  .  .  .  For 
the  muscles  move  certain  parts  upon  which  the  breathing  and  the 

1  De  Usu  Partium.  Lib.  VII,  Cap.  14,  (Kiihn)  III,  p.  567.  For  a  discussion 
of  this  subject,  witli  an  interesting  account  of  a  modern  theory,  see  The  Lancet, 
1893,  I,  p.  128. 

2  De  Locis  Affectis.  Lib.  I.  Cap.  VI,  (Klihnj  VIII,  p.  48.  According  to  Baas, 
Marinus  (100  a.d.)  discovered  the  inferior  larj-ngeal  nerves.  He  gives  no 
reference. 

»  Vid.  Galen:  De  Placitis  Platon.  ct  Hippocrat.,  Lib.  II,  Cap.  II,  (Kiihn) 
V,  p.  215. 

••  De  Natura  Dcorum,  II,  59:  Primum  enim  a  puhiionibus  arteria  usque 
ad  OS  intimum  perlinet,  per  quam  vox  principium  a  nientc  ducens  percipitur 
et  funditur. 


84  GALEN 

voice  depend,  and  they  themselves  in  their  turn  are  dependent 
on  the  nerves  from  the  brain.  If  you  surround  any  one  of  these 
with  a  hcature,  or  if  you  cut  it,  you  will  render  the  muscle  to  which 
it  is  distributed  motionless,  as  well  as  the  limb  of  the  animal  which 
has  moved  before  the  nerve  was  cut."  Another  evidence  of  Galen's 
familiarity  with  experimentation  on  animals  in  elucidating  the 
function  of  the  laryngeal  nerves  is  to  be  found  further  on  in  the 
same  chapter:  "The  bones  being  removed  from  the  brain,  or  its 
ventricles  in  some  manner  compressed,  immediately  there  is  not 
only  no  voice  or  breathing,  but  the  animal  is  at  once  deprived 
of  all  sensation  and  of  all  motion  during  the  compression." 

Humoral  Pathology. — Galen  adopted  Hippocrates'  idea,  and 
thought  health  resulted  from  the  proper  equilibrium  of  the  four 
humors,  the  temperaments,  so  called,  resulting  from  the  preponder- 
ance of  one  or  more  humors.  He  applied  the  four  qualities  to  the 
four  elements  thus: 

Water Cold  and  wet. 

Earth Cold  and  dry. 

Air ^^"arm  and  wet. 

Fire Warm  and  dry. 

He  applied  to  the  humors  the  theory  of  the  elements.  Every 
disease  is  engendered  by  one  of  the  humors  or  several  combined. 
"The  phlegm  is  an  imperfect  blood  which  may  become  true  blood 
by  the  action  of  the  natural  heat  of  the  body.  In  the  phlegm  water 
is  abundant.  It  is  cold  and  wet  like  w^ater.  It  nourishes  the 
brain  and  all  cold  and  wet  parts.  It  tempers  the  blood  and  aids 
the  movements  of  the  articulations."  We  thus  see  it  has  directly 
to  do  with  the  mucous  and  serous  membranes.  In  its  other  rami- 
fications the  description  of  the  applications  of  this  doctrine  is 
prolix  and  fatiguing.  Its  adoption  tended  to  suppress  originality 
of  thought,  just  as  any  system  always  does. 

I  have  detailed  at  considerable  length  the  indications  of  the 
anatomical  and  physiological  knowledge  which  Galen  possessed  of 
the  upper  air  passages,  not  only  because  in  his  work  we  first  meet 
with  any  considerable  notice  of  such  knowledge,  but  because  this 
knowledge  formed  the  basis  upon  which  rested  for  more  than  a 
thousand  years  the  superstructure  of  theory  and  practice,  until, 
indeed,  it  received  from  Vesalius  and  his  followers  a  rational 
criticism,  and  eventually  a  refutation  of  his  doctrines  of  pathology. 
The  abolition  of  the  latter  by  the  physicians  of  the  Renaissance 
and  later,  was  a  boon  to  suffering  humanity.  It  was  one  of  the 
many  fetters  which  bound  the  human  intellect — may  we  never  see 
its  like. 

As  to  other  passages  of  interest  concerning  the  nose  and  throat 
in  the  works  of  Galen,  those  treating  of  their  diseases  need  not 
detain  us  long. 


POLYPI  AND  OZ.ENA  85 

Anosmia. — We  have  seen  the  defects  in  Galen's  knowledge  of  the 
anatomy  and  physiology  of  the  nose,  and  hence  we  need  not  be 
surprised  that  he  instances  obstructive  anosmia  as  a  condition 
in  which  the  air  may  pass  through  the  cribriform  plate  to  the  brain 
without  the  odor — the  particles  of  the  latter  being  too  large  to 
pass  through  the  perforations  in  the  membrane  lining  the  cribriform 
plate.  ^ 

As  a  further  illustration  of  the  supposed  entrance  of  the  air  or 
rather  of  the  "pneuma"  into  the  brain,  he  instances  the  case  of  a 
man  who  after  forcible  inhalation  of  an  irritating  substance  into 
the  nose,  suffered  acutely  with  headache  referred  to  the  frontal 
region. - 

Polypi  and  Ozsena. — Galen  seems  to  have  divided  diseases  of  the 
nose  into  two  classes,  polypi  and  ozaena — corresponding,  perhaps, 
to  the  modern  classification  of  hypertrophic  rhinitis,  including 
cedematous  hypertrophy  and  polypi,  and  atrophic  rhinitis  including 
possibly  syphilis,  if  it  then  existed.  Elsewhere,  however,  among 
the  Definitions^  (Xo.  371),  he  states  that  oza^na  is  a  deep  ulceration 
in  the  nostrils,  emitting  a  breath  of  a  bad  odor,  and  says:  "Sarcoma 
is  the  unnatural  growth  of  flesh  within  the  nostrils.  Indeed,  a 
polyp  is  a  kind  of  sarcoma.  ...  A  sarcoma  differs  from  a  polyp 
in  size  and  structure."  His  differentiation  of  nasal  disease  was, 
of  course,  very  faulty.  He  gives  a  very  large  number  of  prescrip- 
tions, both  of  his  own  and  others,  for  the  so-called  ozsena  and  polypi, 
but  his  therapy  for  these  affections  is  decidedly  inferior  to  that  of 
Celsus.  In  the  treatment  of  ozsena  many  compounds  of  iron  or 
copper  salts  with  honey,  myrrh  and  other  sweet-smelling  herbs 
were  introduced  into  the  nostrils  through  tubes.  Archigenes 
Asclepiades,  Antipater,  Charixenes,  and  many  others  are  referred 
to  by  Galen  as  recommending  these  mixtures  both  for  "polypi"  and 
for  ozaena.  Oily  applications,  goose  fat,  calf  tallow,  and  irritating 
medicaments  like  turpentine  were  also  employed.  A  fuller  account 
of  this  therapy  may  be  foinid  culled  from  Galen  in  Kassel's  book, 
but  as  the  diff'erentiation  of  intranasal  disease  is  entirely  lacking 
in  the  modern  sense,  it  would  be  a  work  of  supererogation  to  repeat 
his  extracts.  There  is  no  reference  made  to  Hippocrates'  method 
of  removing  nasal  polypi.  Considerable  attention  is  given  to 
epistaxis  as  a  symptom  of  various  general  diseases,  but  not  as  much 
stress  is  laid  upon  this  point  as  in  the  Hippocratic  treatises.  He, 
as  did  his  predecessors,  recognized  the  dependence  of  diseases  of 
the  larynx  upon  affections  of  the  parts  above,  but  they  explained 
this  by  the  assumption  that  the  brain  was  the  common  origin  of 
all  catarrhs.  We  find  in  Gakni  abundant  evidence  of  the  influence 
of  what  I  have  called  Chaldean  medicine,  the  excrement  of  men 
and  animals  being  freel}^  used  in  throat  inflammations.     Bleeding 

1  De  Usu  Partium,  Lib.  VIII,  Cap.  VI,  (Kiihn)  III,  i).  (W(5. 

^  De  Instrumentum  Udoratus.  ^  (Kiihn)  XIX,  p.  440. 


86  GALEN 

from  beneath  the  tongue  was  also  a  favorite  remedy  in  all  afi'ections 
of  the  pharynx  and  larynx. 

Varieties  of  Kynanche. — We  have  seen  how  Celsus  and  Aretaeus 
subdivided  infiamiuations  of  the  throat  into  kynanche  and 
synanche.  Galen  refers'  to  the  ])ook  of  Prognostics  of  IIip])ocrates 
to  prove  that  all  these  inlianimations  were  at  first  called  kynanche. 
Galen  himself,  while  not  disposed  to  increase  the  number  of  names, 
divides  throat  inflammations  into  five  varieties.  First,  inflamma- 
tion of  the  fauces.  Second,  difficulty  of  breathing  with  no  inflamma- 
tion of  the  fauces  or  swelling  of  the  external  parts.  Third,  when 
the  region  of  the  fauces  externally  is  inflamed.  Fourth,  when  the 
fauces  internally  and  externally  are  inflamed.  This  all  seems  very 
nonsensical,  but  we  must  remember  the  influence  of  the  school  of 
pneumatists.  Although  Galen  supplanted  all  schools,  he  was  by 
no  means  himself  free  from  the  influence  of  many  of  their  theories. 
Fifth,  in  both  Galen  and  Hippocrates  there  is  a  description  of  a 
throat  affection  which  Galen  explained  as  a  dislocation  of  the  odon- 
toid process  of  the  axis  vertebra.  I  am  entirely  at  a  loss  to  identify 
this  affection,  unless  it  was  a  postpharyngeal  abscess.  They  both 
speak  of  it  as  an  affection  more  or  less  commonly  met  with,  and 
Galen  created  a  fifth  class  for  it. 

Diphtheria. — If  any  doubts  have  arisen  as  to  the  correctness  of 
the  assumption  that  diphtheria  was  known  to  earlier  writers,  the 
following  passage  from  Galen  should  set  the  matter  at  rest.  It 
occurs  incidentally  in  Galen's  treatise  on  therapeutics.-  "For  thus 
the  youth  having  an  ulcer  of  the  pestilential  disease  in  the  trachea 
regained  his  health,  and  others  in  the  same  manner  after  him.  In 
another  youth,  about  eighteen  years  old,  a  cold  having  gone  on 
for  many  days,  a  little  fluid  blood  came  up  after  a  cough — not 
much — but  after  this  he  coughed  up  some  part  of  the  membrane 
itself,  which,  having  remained  behind  in  the  trachea,  came  up 
through  the  larynx  into  the  j^harynx  and  mouth.  It  seemed  to 
me  from  the  apparent  thickness  of  it  and  from  the  patient's  sensa- 
tions, it  came  from  the  body  of  the  larynx.  Thenceforth  the  man's 
voice  was  injured,  and  this  for  some  time,  but  he  eventually 
recovered." 

latros.- — Thus  far  in  making  citations  from  the  works  of  Galen 
I  have  refrained  from  quoting  from  "latros,  or  The  Surgeon,"  a 
book  usually  included  in  the  more  authentic  works  of  Galen. 
While  the  latter  may  have  written  the  introductory  parts,  nothing 
can  be  more  certain  than  that  he  is  not  responsible  for  the  })ody  of 
the  work.  Evidently  it  is  the  work  of  another  and  a  much  inferior 
hand.  It  is  full  of  anatomical  and  physiological  errors  which 
Galen  himself  in  his  other  works  has  refuted  or  shown  tliat  he  did 
not   share.      Galen's   great   familiarity   with   Hippocrates   would 

1  De  Locis  Affect.,  Lib.  IV,  Cap.  VI,  (Ktihn)  VIII,  p.  237. 

2  De  Mcthodo  Mcdondi,  Lib.  \,  Cap.  XII,  (Kiilin)  X,  p.  360. 


lATROS  87 

haA'e  prevented  him  from  making  the  statement  we  find  in  the 
"latros"  that  if  the  nasal  bones  are  broken  they  cannot  be  straight- 
ened. Galen  in  his  "Commentaries  on  the  Hippocratic  Treatises," 
dealing  with  this  subject,  shows  his  perfect  familiarity  with  the 
treatment  of  such  cases. ^  We  find  also  that  the  author,  whoever 
he  was,  made  the  same  distinction  between  kvnanche  and  svnanche 
as  did  Celsus  and  Aretaeus,  a  distinction  which  Galen,  as  we  have 
seen,  distinctly  repudiates.  He  agrees  with  Galen  in  attributing 
great  importance  to  the  epiglottis  as  a  protection  to  the  larynx, 
but  he  fails  to  add  any  precept  of  caution  to  his  mention  of  the 
operation  of  amputation  of  the  uvula  to  which  Galen  attached  such 
necessary  physiological  functions.  He  speaks  of  the  tonsils  as 
four  in  number,  one  at  each  side  of  the  fauces,  and  one  at  each 
side  of  the  base  of  the  tongue,  this  being  the  first  mention  of  the 
lingual  tonsil.  He  used  a  sharp,  narrow  spatula  to  separate  nasal 
polypi  from  the  bone,  and  afterward  shaved  off  the  roots  with  a 
sharp  knife.  It  is  in  this  book  that  the  assertion  is  positively  made 
that  Asclepiades  actually  performed  laryngotomy  in  extreme  cases 
of  dyspnoea,  but  there  is  no  comment  with  the  statement. 


THE  GREEK  WRITERS  OF  THE  EASTERN  EMPIRE. 

And  now  begins  that  long  and  dreadful  epoch  in  the  history  of 
mankind  when  civilization  was  almost  o^'erwhelmed  in  the  slowly 
crumbling  ruins  of  the  Roman  Empire.  Julius  and  Augustus 
Caesar,  in  extinguishing  the  anarchy  of  the  last  days  of  the  Republic, 
extinguished  with  it  much  of  that  burning  fire,  the  love  of  human 
liberty,  which  has  always  blazed  high  in  lighting  the  progress  of 
civilization.  Tiberius,  Caligula,  Claudius,  Xero,  Domitian  spilled 
the  best  blood  of  patrician  Rome  and  demonstrated  the  horrible 
evils  of  a  despotism  under  weak  and  wicked  men.  Xerva,  Trajan, 
Hadrian,  the  Antonines  demonstrated  the  enormous  but  temporary 
advantages  to  mankind  of  a  despotism  under  virtuous  and  capable 
rulers,  but  by  the  time  they  had  passed  away,  the  ^•irtue,  and  the 
sense  of  responsibility,  the  power  of  initiative,  had  long  since 
perished.  Anarchy  and  ruin  began  to  spread  over  the  world,  and 
the  powers  of  darkness,  oriental  sorcery,  the  incantations  of  ignorant 
priests,  the  vulgar  fanaticism  of  a  nascent  religion  with  all  its 
superstitious  dross,  unrefined  and  unrestrained,  held  high  carni^•al 
in  the  temples  of  science  and  the  advance  in  the  art  of  medicine 
ceased,  and  for  many  hundreds  of  years  the  best  we  can  say  of 
medical  writers  such  as  Oribasius,  Aetius,  and  Paulus  Aegineta 

1  Also  in  the  De  Fascibus:  In  the  Basel  Edition  of  Galen,  1586,  VI,  p.  299  et 
seq.,  may  be  found  a  number  of  wood-cuts  illustrating  in  the  most  graphic 
manner  the  methods  Galen  describes  for  nasal  bandaging,  including  those 
suggested  by  Hippocrates,  Phalera,  and  Amj-ntas. 


88         THE  GREEK   WRITERS  OF   THE  EASTERN  EMPIRE 

is  that  they  copied  with  tolerable  accuracy  from  the  writings  of 
others,  intruded  few  of  their  own  ideas,  and  the  admission  to  their 
pages  of  incantations,  the  descriptions  of  amulets  and  cabalistic 
figures,  the  recommendations  of  Chaldean  drugs  are  no  more  than 
the  perusal  of  the  history  of  their  times  should  lead  us  to  expect. 
Attempts  were  made  to  check  this  tendency  toward  magical 
therapy.  Thus  Serenus  Sammonicus,^  the  elder,  was  put  to  death 
by  the  orders  of  the  savage  Caracalla  (211  a.d.)  because  he  recom- 
mended amulets  as  remedies  for  intermittent  fever  (Sprengel). 
He  or  his  son  wrote  a  medical  poem  (Edit.  Ackermann)  in  which, 
among  numberless  other  remedies,  he  advised  the  application 
externallj'  by  friction  of  bull's  grease  or  bear's  grease  to  the  neck 
in  cases  of  sore  throat,  besides  the  popular  prescription  of  vinegar 
as  a  gargle.  Such  remedies  are  still  popular  ones  on  every  country 
hillside. 

Constantinople.- — Constantine  founded  his  great  city  at  Byzantium 
and  moved  thither  the  capitol  of  the  world'  (330  a.d.).  Julian  the 
Apostate,  his  grandson,  in  his  attempt  to  revive  the  old  pagan 
religion  engaged  also  in  the  more  laudable  endeavor  to  resuscitate 
the  learning  of  the  ancients.  Oribasius  accompanied  him  in  his 
campaigns  in  Gaul  before  his  accession  (361  a.d.)  to  the  throne  of 
Constantine,  and  to  him  was  delegated  the  task  of  collecting  and 
epitomizing  the  works  of  former  masters  in  the  art  of  medicine. 
The  works  of  Galen  are  the  chief  sources  from  which  he  made  his 
compilation,  but  unfortunately,  unlike  Caelius  Aurelianus  and 
Paulus  Aegineta,  and  indeed  Galen  himself,  Oribasius  only  reveals 
to  us  knowledge  of  the  diseases  of  the  upper  air  passages  which  is 
accessible  to  us  at  its  source.  There  is  scarcely  a  passage  of 
any  importance  concerning  the  nose  and  throat  which  we  have 
not  already  noted  in  the  works  from  which  this  author  drew  his 
information. 

It  was  in  vain  that  Julian  in  his  short  reign  attempted  to  revive 
ancient  learning.  Succeeding  rulers  of  a  groveling  despotism, 
although  themselves  occasionally  enlightened  and  virtuous,  were 
unable  to  bring  back  the  old  free  spirit  which  produced  the  age  of 
Pericles  and  the  era  of  Augustus.  1  may  again  quote  the  remarks 
of  the  sententious  Gibbon:  "The  subjects  who  had  resigned  their 
wills  to  the  absolute  commands  of  a  master  were  equally  inca])able 
of  guarding  their  lives  and  fortunes  against  the  assaults  of  the 

'  Serenus  Sammonicus  was  a  firm  believer  in  the  magical  efficacj'  of  the 
triangular  arrangement  of  the  word  Abracadabra  written  on  a  piece  of  paper 
folded  into  the  form  of  a  cross,  tied  up  in  a  piece  of  linen  cloth  and  placect  over 
the  pit  of  the  stomach,  to  be  worn  nine  days,  and  then  before  sunrise  cast  over 
the  shoulder  into  running  water. 

*  Christianity  began  in  Gaul  in  the  middle  of  the  second  century,  in  the  time 
of  Galen,  Lyons  having  the  first  clnu-ch,  and  so  rapid  was  the  spread  of  the 
new  faith  that  two  hundred  years  later  Constantine  the  Great  found  it  to  his 
interest  to  embrace  the  forms  of  Christianity  as  his  ostensible  faith  and  to 
free  the  church  from  taxation. 


THE  EASTERN  EMPIRE  89 

barbarians,  or  of  defending  their  reason  from  the  terrors  of  super- 
stition." The  Roman  world  was  divided  at  its  hne  of  natural 
cleavage  between  the  oriental  and  the  occidental  races  of  mankind. 
The  Eastern  Empire  lived  many  centuries  at  Constantinople  in 
the  reflection  of  the  light  of  the  old  world  of  Galen  and  Hippocrates, 
but  it  was  around  the  western  shores  of  the  ]Mediterranean,  as 
formerly  along  the  coasts  of  the  Aegean,  that  civilization  was, 
after  many  hundretl  years,  again  to  assume  a  new  life  and  a  new 
vigor.  On  the  death  of  Theodosius  (395  a.d.),  the  last  great  Roman 
emperor,  the  mighty  fabric  fell  apart  forever,  and  under  Honorius 
and  his  equally  impotent  successors,  after  the  death  (40S  a.d.) 
of  Stilicho,  the  great  commander,  the  Western  Empire  was  deluged 
by  the  hordes  of  Goths  and  Msigoths,  by  the  Huns  and  Vandals, 
and  anything  like  medical  learning  utterly  perished  with  the  other 
arts  from  that  part  of  the  face  of  the  earth.  The  barbarians  were 
converted  to  Christianity,  and  their  monks,  in  the  search  for  means 
of  saving  their  souls  from  eternal  torment,  found  it  necessary  to 
study  the  Holy  vScriptures.  Their  rude  chieftains  in  their  search 
for  methods  of  legal  procedure  and  orderly  administration  found 
it  necessary  to  study  the  codes  of  Roman  law.  These  circumstances 
finally  brought  about  their  familiarity  with  Latin  and  Greek  litera- 
ture. Virgil,  Cicero,  Livy,  contributed  to  the  amelioration  of 
their  manners  and  the  expansion  of  their  intellects,  while  Galen, 
Pliny,  and  Celsus  eventually  transmitted  to  them  the  seeds  of 
medical  science,  which  had  matured  in  the  old  civilization,  and 
had  been  almost  lost  in  its  annihilation.  Cassius  Felix  was  a  medical 
writer  who  is  supposed  to  have  lived  in  the  fifth  century.  His 
book,^  as  he  confessed,  was  mostly  made  up  of  extracts  from  the 
earlier  Greek  writers.  He  thus  speaks  of  what  is  apparently 
diphtheria : 

Diphtheria. — "  Ulceration  of  the  fauces,  if  accompanied  by  acute 
fever  in  sickness,  is  found  to  be  very  bad  and  fatal,  especially  if 
it  has  begun  with  severity.  There  is  moreover  another  inflammation 
besides  the  acute  fever,  which  forms  in  the  deep  recesses  of  the 
mouth,  white  or  black,  or  rather  dusky  gray  patches,  which  they 
call  tephros  (ash  colored).  It  is  usually  called  by  the  Greeks, 
Aphtha,  which  we  call  'coction'  of  the  mouth.  And  it  is  worse, 
even  deadly,  in  young  nursing  infants  on  account  of  the  tender  age." 

There  is  no  mistaking  this  blending  of  aphthous  sore  mouth 
with  true  diphtheria. 

The  Eastern  Empire. — The  Eastern  Empire  preserved  the  vestiges 
of  Greek  learning,  all  but  suffocated  by  the  sorcery  and  witchcraft 
which  apparently  have  always  found  such  a  fertile  soil  beyond  the 
Hellespont.  Nemesius,  a  bishop  of  Emesa  in  Syria,  lived  during 
the  reign  of  Theodosius  (370-395  a.d.)  and  wrote  a  book  on  the 

1  Cassii  Felicis  De  Medicina  (Edit.  Val.  Rose).    Lipsiae,  1879. 


90         THE  GREEK   WRITERS  OF  THE  EASTERN  EMPIRE 

"Nature  of  Man,"  in  which  the  old  critics,  envious  of  the  fame  of 
Harvey,  used  to  })retend  to  find  the  discovery  of  the  circulation 
of  the  blood.     In  this  book  there  is  a  chapter  on  the  respiration, 
and  in  it  we  find  the  author  describing  tiie  larynx  under  the  name 
of  the  bronchus,  and  following  Galen  in  saying  it  is  made  up  of 
three  cartilages.     It  is  Marcellus,  very  aptly  called  "Empiricus," 
however,  who  best  illustrates  the  condition  of  medical  learning  at 
this  time.     He  was  a  Gaul,  born  at  Bordeaux,  and  though  a  high 
officer  of  Theodosius  and  his  son  Arcadius,  exhibits,  as  Sprengel 
remarks,  the  soul  of  a  slave  in  his  works,  recommending  certain 
remedies  because  they  were  used  by  the  Diva  Augusta  or  the  Diva 
Livia.     His  work  "De  INIedicamentis"  is  said  to  have  been  much 
mutilated  by  later  editors.     Chapter  X  deals  with  the  diseases 
of  the  nose,  coryza,  polypus,  ozsena,  nose-bleed,  or  rather  with  their 
treatment;  for  few  writers  after  Galen  devote  much  space  to  any- 
thing but  the  transcription  of  multitudinous  formulte.     V\e  will 
not  pretend  to  mention  the  innumerable  drugs,  but  we  note  that 
he  recommends  the  prescription  of  Pliny  that  a  man  whose  nose 
stinks  should  kiss  the  nostrils  of  a  he-mule,  and  if  the  patient  is  a 
woman  she  should  kiss  the  nostrils  of  a  she-mule.     Besides  drugs 
which  are  orthodox  now%  all  kinds  of  stercoraceous  applications 
are  recommended.    ^Yhen  the  nose  is  bleeding  it  is  helpful  to  say 
three  times  in  the  ear  of  that  side  some  unintelligible  jargon. 
However  much  we  may  have  to  criticise  in  ]\larcellus,  there  is  one 
axiom  which  he  lays  down  which  is  not  always  found  in  preceding 
authors  and  is  often  disregarded  by  his  successors.    In  his  chapter 
on  affections  of  the  throat,  he  says:   "For  a  swelling  of  the  fauces 
and  of  the  palate  everything  used  in  the  prescription  should  have 
no  irritating  quality;"  but  the  very  efficacious  prescription  which 
follows    contains    the    juice    of    sour    grapes — Sprengel    surmises, 
because  the  Latin  word  uva  means  both  grape  and  uvulitis;  but 
we  have  seen  that  the  juice  of  unripe  fruits  was  a  favorite  prescrip- 
tion for  this  affection  among  both  the  Hindus  and  the  early  Greeks. 
This,  however,  is  his  incantation  for  pain  in  the  throat,  which  he 
who  suffers  should  sing  to  himself:    "  Grissi  crasi,  cancrasi — put 
the  hand  on  the  throat  and  repeat  it  three  times." 

Incantations  and  Amulets. — Besides  the  usual  inevitable  swallow 
prescription  of  the  ancients  w-e  find  also  this  remarkable  modifica- 
tion of  it:  "This  cure  will  help  one  suffering  with  chronic  sore 
throat.  You  must  shut  up  a  live  swallow  in  the  cavity  of  an 
African  shell  and  this  being  tied  up  in  the  linen  cloth  of  Egypt, 
you  shall  hang  it  around  the  neck  and  on  the  ninth  day  you  will 
be  free  of  your  trouble."  And  this  is  another  elaboration  of  the 
swallow  prescription  a])parently  derived  from  Dioscorides:  "But 
especially  against  synanche  it  is  useful  if  you  will  take  young 
swallows  alive  in  the  nest,  and  will  burn  these  alive  so  that  a 
powder  is  made  from  them   (their  ashes)  on  the  day  of  Jupiter 


INCANTATIONS  AND  AMULETS  91 

in  old  moon,  but  look  to  it  that  you  find  unequal  numbers^  in  the 
nest  and  that  you  burn  as  many  as  there  are,  and  you  will  give 
this  powder  mixed  up  with  warm  water  as  a  drink,  and  with  the 
finger  covered  with  the  powder  you  will  touch  the  place  of  the 
synanche  from  the  inside.  You  will  greatly  admire  this  prescrip- 
tion." And  then  come  some  more  incantations,  long  and  involved. 
As  an  amulet  some  Greek  jargon  was  to  be  written  on  a  paper 
which  was  to  be  wrapped  in  linen  and  hung  around  the  neck  for  a 
sore  throat.  Another  mysterious  formula  was  to  be  used  in  the 
same  way  for  a  bone  in  the  throat.  While  I  have  not  exhausted 
Marcellus'  savory  pharmacopoeia  in  any  of  its  branches  it  is  under- 
stood, of  course,  that  these  selections  are  made  from  many  others  of 
a  more  rational  nature  which  have  not  even  the  virtue  of  originality 
nor  the  interest  which  always  attends  the  mysterious  in  thera- 
peutics. Indeed,  to  do  him  justice,  he  only  speaks  of  the  incanta- 
tions, as  a  rule,  after  mentioning  many  of  the  routine  prescriptions 
which  are  found  in  the  writings  of  an  earlier  and  a  happier  age. 

As  we  have  seen,  there  was  an  interval  of  two  hundred  years 
(660-460  B.C.)  between  the  introduction  of  written  records  into 
Greece  and  the  birth  of  Hippocrates.  This  doubtless  included  that 
period  when  the  record  was  engraved  on  the  column  of  the  temple 
of  Aesculapius  at  Epidaurus  of  a  sacred  dog  curing  a  cervical  tumor 
by  licking  it.  From  the  birth  of  Hippocrates  to  that  of  Galen, 
six  hundred  glorious  years  of  medical  progress  intervened.  We 
have  seen  the  high  state  of  anatomical  knowledge  revealed  in  the 
works  of  Galen.  From  the  death  of  Galen  to  the  time  of  ]\Iarcellus 
approximately  another  two  hundred  years  had  elapsed.  The  holy 
dog  of  Epidaurus  finds  a  mate  in  the  live  swallow  of  Marcellus. 
"Facilis  descensus  Averno."  As  illustrative  of  the  times  and  as 
containing  a  matter  of  some  interest  to  our  subject,  I  again  quote 
from  a  page  of  Gibbon  (HI,  Cap.  XXXVH).  A  war  had  been 
raging  in  Africa  between  the  Arians  who  denied  and  the  Catholics 
who  upheld  the  Trinity.  It  resulted  in  the  discomfiture  of  the 
latter  (530  a.d.).- 

"A  military  count  was  dispatched  from  Carthage  to  Tipasa;  he 
collected  the  Catholics  in  the  Forum,  and,  in  the  presence  of  the 
whole  province,  deprived  the  guilty  of  their  right  hands  and  their 
tongues.     But  the  holy  confessors  continued  to   speak  without 

1  Tema  tibi  haec  priinum  triplici  diversa  colore 
Lioia  circumdo,  terque  haec  altaria  circum 
Effigiem  duco;  mtmero  dens  impnre  gnndet. 

— \'irgil  Kcloga)  VIII,  73-75. 
"For  there's  luck  in  odd  uuinlxM's,  says  Rory  O'More." — Sam'l  Lover. 
-  The  motto  of  the  Church  later,  "Ecclesia  abhorret  a  sanguine,"  was  hardly 
appUcable  to  this  period.     Macchiavelli,  referring  to  these  African  religious 
troubles  in  his  Istorie  Florentine,  says:     "Vivendo  adunque  gli  uomini  intra 
tantepersecuzioni  portavano  descritto  negli  occhi  lo  spavento  dell'  anime  loro." 
The  men  living  then  amidst  such  persecutions  carried  written  in  their  eyes 
the  terror  of  their  souls. 


92         THE  GREEK   WRITERS  OF  THE  EASTERN  EMPIRE 

tongues;  and  this  minicle  is  attested  by  Victor,  an  African  bishop, 
who  pubHshed  a  history  of  the  persecution  two  years  after  the 
event.  'If  any  one,'  says  Victor,  'should  doubt  of  the  truth,  let 
him  repair  to  Constantinople,  and  listen  to  the  clear  and  perfect 
language  of  Restitutus,  the  sub-deacon,  one  of  these  glorious 
sufferers,  who  is  now  lodged  in  the  palace  of  the  Emperor  Zeno, 
and  is  respected  by  the  devout  Empress.'  At  Constantinople  we 
are  astonished  to  find  a  cool,  a  learned,  an  unexceptional  witness, 
without  interest,  and  without  passion.  Aeneas  of  Gaza,  Platonic 
philosopher,  has  accurately  described  his  own  observations  on 
these  African  sufferers;  'I  saw  them  myself;  I  heard  them  speak; 
I  diligently  inquired  l\v  what  means  such  an  articulate  voice  could 
be  formed  without  any  organ  of  speech;  I  used  my  eyes  to  examine 
the  report  of  my  ears;  1  opened  their  mouth,  and  saw  that  the 
whole  tongue  had  been  completely  torn  away  by  the  roots,  an 
operation  which  physicians  usually  suppose  to  be  mortal.'  "  The 
operations  now  done  for  the  extirpation  of  the  tongue  have  proved 
that  the  tongue  is  not  the  indispensable  organ  of  speech,  but  what 
would  Galen  or  Aeneas  say  if  they  should  now  be  shown  that  the 
larynx  is  not  the  indispensable  "instrument  of  the  voice?" 

Aetius. — Aetius  is  said  to  have  lived  as  a  medical  officer  of  the 
court  at  Constantinople  about  the  middle  of  the  sixth  century. 
He  was  an  Asiatic  of  Amida  in  Mesopotamia.  After  Oribasius, 
he  was  perhaps  the  best  of  those  who  transcribed  the  works  of 
Galen  and  the  older  writers.  There  is  a  great  deal  in  his  works 
(The  Tetrabiblion)  concerning  the  nose  and  the  throat,  but  very 
little  w^e  have  not  met  with  elsewhere.  Uvulotomy  and  tonsillotomy 
and  the  incision  of  a  quinsy  are  the  surgical  operations  described. 
He  warns  against  the  dangers  of  secondary  hemorrhage  in  ton- 
sillotomy and  directs  that  only  that  part  of  the  gland  which 
projects  shall  be  cut  oft".  If  even  a  small  portion  of  the  normal 
underlying  tissue  is  removed  there  is  danger  of  hemorrhage.  He 
was  familiar  with  diphtheria  and  with  adhesions  in  the  larynx 
resulting  therefrom,  or  possibly  he  refers  only  to  the  acute  stenosis. 
Alum,  nutgalls,  mercury,  besides  bryonia,  and  many  other  vegetable 
and  mineral  astringents  and  emollient  drugs  are  recommended 
by  him.  He  fully  equalled  jMarcellus  in  stercoraceous  pharma- 
cology. Incantations  are  less  numerous  perhaps,  but  not  by  any 
means  absent  from  his  writings.  He  recommends  the  use  of  forceps 
in  extracting  bones  and  foreign  bodies  from  the  tonsils.  ^Yhen 
they  were  in  the  gullet,  the  patient  swallowed  a  sponge  with  a 
string  attached  to  it,  by  which  it  was  then  hauled  up.  For  this 
trouble  he  also  advises  the  repeated  swallowing  of  bread  boluses. 
It  is  said  the  following  is  the  first  mention  of  the  Saviour  in  medical 
writings:^    "Moreover  for  the  removal  of  those  things  which  are 

'  Tcfrab.  II  Sormo  IV,  Cap.  L.  Galen  is  said  to  nu'iilion  the  Christians  in 
a  book  extant  in  Arabic  (Historia  Antcisiam  Abulteda>.  Ed.  Fleischer,  p.  109). 


OLFACTORY  NERVES  93 

stuck  in  the  tonsils,  immediately  take  a  seat  in  front  of  the  patient 
and  command  him  to  harken  to  thee,  and  thou  shalt  say:  'Come 
out,  bone'  (if  indeed  it  is  a  bone  or  a  straw,  or  whatever  it  may 
be),  'in  the  same  way  as  Jesus  Christ  raised  Lazarus  from  the 
grave,  and  in  the  same  manner  as  Jonah  came  from  the  whale.' 
Then  seizing  the  patient  by  the  throat,  exclaim:  'Blasius,  the 
martyr  and  servant  of  Christ,  says  come  up  or  go  down.'  " 

This  must  have  been  excellent  treatment  for  globus  hystericus 
among  the  faithful. 

Shortly  after  Aetius,  lived  Alexander  to  whom  the  surname  of 
Trallianus  is  given,  he  being  one  of  the  five  talented  sons  of  a 
citizen  of  Tralles.  He  was  the  brother  of  Metrodorus,  the  gram- 
marian, and  of  that  Anthemius  who  was  the  architect  of  the  great 
church,  now  the  mosque  of  St.  Sophia  in  Constantinople,  which 
was  built  (532  a.d.)  by  Justinian  and  his  consort,  the  fair  Theo- 
dora, the  licentious  Cyprian  prostitute  who  disgraced  even  the 
stage  of  Constantinople  before  she  sullied  the  much-stained  purple 
of  the  Caesars.^  Although  there  are  many  instances  of  thaumaturgy 
in  his  works,  Alexander  Trallianus  practised  at  Rome  with  honor 
and  profit,  and  was  perhaps  the  most  enlightened  physician  and 
the  least  tainted  with  superstition  of  any  who  had  succeeded 
Galen,  but  while  he  has  written  chapters  on  the  diseases  of  the 
nose  and  throat,  there  is  nothing  in  them  to  especially  arrest  our 
attention.  Of  a  very  different  character  was  Sextus  Placitus 
Papiensis,  who  outstripped  even  Marcellus  and  Aetius  in  the  use 
of  the  viscera  of  animals  and  equaled  them  in  other  departments 
of  Chaldean  pharmacology.- 

Olfactory  Nerves. — Theophilus,  a  colonel  of  the  guard  under 
Heraclius  (GIO  a.d.),  seems  to  have  been  one  of  the  very  few  medical 
writers  who,  in  copying^  from  the  Avorks  of  Galen  and  others, 
troubled  themselves  with  transcribing  any  of  the  anatomy  or 
physiology  or  semeiology,  of  which  they  were  in  such  need.  Even 
he  is  very  inexact.  The  teleology  so  prominent  in  the  work  of 
Theophilus  is  by  no  means  absent  from  that  of  his  great  predecessor, 
Galen,  but  the  former  wishes  to  explain  every  function  in  a  manner 
tending  to  the  glory  of  God,  and  he  remarks  upon  the  use  of  the 
epiglottis  in  protecting  the  larynx,  that  if  a  crumb  fall  in  it,  owing  to 
the  lack  of  proper  action  on  the  part  of  the  epiglottis,  the  patient  is 
suffocated,  which  is  a  gross  exaggeration  of  even  Galen's  remarks  in 
the  same  vein.  His  ideas  of  the  purposes  of  the  Almighty  in  perfor- 
ating the  dura  mater  and  the  cribriform  plate  of  the  ethmoid  would 
hardly  be  orthodox  today,  illustrating  how  dangerous  are  dogmatic 
statements  outside  of  the  domain  of  theology.  The  only  advance 
over  the  ideas  of  Galen  which  1  am  able  to  note  in  Theophilus 

1  Gibbon:  The  Decline  and  Fall  of  the  Roman  Empire,  Vol.  IV,  Cap.  XL. 
-  De  Mcdicamcntis  ex  Animalibus  Liber.  (Ackermann.)  Norimberga>,  1788. 
3  De  Homin.  Fabric.,  Lib.  Ill,  Paris,  1555. 


94        THE  GREEK  WRITERS  OF  THE  EASTERN  EMPIRE 

is  the  point  to  which  several  historians  liave  drawn  attention. 
He  ac'('ei)ted  the  Galenic  and  llippocratic  idea  of  air  inspired 
and  excretions  drained  through  the  perforations  in  the  cribriform 
plate.  He  also  supposed  that  through  the  perforations  go  the 
odorous  particles.  It  is  perfectly  evident  that  he  recognized^ 
"the  first  pair  of  nerves  as  starting  from  the  anterior  ventricles 
of  the  brain  and  going  to  the  foramen  of  the  nose  on  each  side,  on 
account  of  which  the  brain  perceives  odors,"  but  as  the  presence 
of  the  nerve  fibers  in  the  perforations  would  be  inconsistent  with 
the  idea  of  their  patency,  we  must  conclude  that  Theophilus  knew 
nothing  of  the  distribution  of  the  olfactory  twigs.  As  his  was  a 
text-book  in  the  schools  of  the  pre-Renaissance  period,  this  inter- 
pretation would  certainly  have  been  recognized  if  justified  by  the 
text. 

Neither  the  Pandects  or  legal  reforms  of  Justinian,  nor  the 
virtuous  reigns  of  Tiberius  H  and  Maurice  (578-610  a.d.),  were 
of  avail  in  arresting  the  degredation  of  the  Empire  of  the  East. 
Justinian  abolished  the  philosophical  school  of  Athens  and  the 
consulship  of  the  old  Roman  regime,  but  they  were  long  since 
become  mere  shadows  which  were  brushed  away  w^ithout  harm  and 
without  profit  to  the  world.  What  bar})arians  had  spared  the 
suicidal  fanaticism  of  the  despicable  Christian  citizens  of  Con- 
stantinople, or  their  equally  cowardly  and  incompetent  rulers, 
destroyed.  Even  under  the  great  Constantine,  every  manuscript 
that  could  be  seized  was  forthwith  destroyed  if  it  contained  any- 
thing of  pagan  learning. 

Paulus  Aegineta. — Under  Heraclius,  whose  victories  shattered 
the  resources  not  only  of  the  hostile  Persian  Empire,  but  the  already 
faltering  forces  of  his  own  (610-641),  we  note  the  last  of  the  Greek 
physicians  whose  works  it  is  worth  while  for  us  to  review  in  our 
search  for  knowledge  of  the  diseases  of  the  nose  and  throat.  We 
are  indebted  to  Paulus  Aegineta  for  much  which  he  has  borrowed 
from  sources  inaccessible  to  us  in  the  original.  It  is  frequently 
impossible  for  us  to  know  how  much  was  original  with  him.^  At 
least,  with  the  exception  of  Alexander  Trallianus,  he  is  almost  the 

1  See  the  1555  Paris  edition.  The  Greek  text  is  so  antiquated  that  I  am 
compelled  to  judge  from  the  Latin  translation  of  the  passage  which  occurs  at 
page  67. 

Theophilus  was  one  of  the  medical  writers  whom  it  was  necessary  to  study 
and  to  teach  at  the  Univerity  of  Paris  when  it  took  its  rise  in  the  thirteenth 
century.  (Sprengel.)  It  may  be  surmised  that  this  choice  was  due  rather  to 
the  theology  than  the  physiology  of  his  works. 

2  Dr.  Francis  Adams'  Sydenham  edition  (London,  1844-47,  3  vols)  of  the 
translated  works  of  Paulus  Aegineta,  which  I  follow,  contains  the  translator's 
comments  on  the  ditTcrcnt  subjects  treated,  and  these  consist  mainly  of  citations 
from  all  the  ancient  writers  on  medicine,  including  the  Arabians.  No  better 
work  can  be  consulted  for  a  review  of  ancient  medical  knowledge,  although 
rarely  there  seem  to  be  grave  errors,  and  the  citations  do  not  usually  guide 
one  to  the  quoted  sources  in  the  texts  of  the  originals.  Unfortunately  the 
text  of  Paulus  does  not  accompany  the  translation. 


THE  KNOTTED  STRING  FOR  NASAL  POLYPI  95 

only  one  after  Galen  whose  works  prove  their  author  capable  of 
any  originality  of  his  own.  Living  in  the  seventh  century,  he 
was  probably  contemporaneous  with  Theophilus. 

We  still  find  aphtha^  in  infants  confused  with  the  graver  disorder 
of  diphtheria.  He  says  that  the  black  variety  of  the  ulcers  is  the 
most  fatal. 

As  in  many  of  the  older  writers  there  is  in  Aegineta  a  chapter 
(1.  c,  sec.  19)  on  the  exercise  of  the  voice,  not  only  for  strengthening 
it  but  as  a  general  exercise  of  the  body.  After  mentioning  the 
operations  for  nasal  polypi^  which  we  have  noted  in  Celsus  and 
Galen,  he  remarks:  "iVfter  the  operation,  having  sponged  the 
parts  carefully,  we  inject  oxy crate  of  wine  into  the  nose,  and,  if 
the  fluid  descend  by  the  roof  of  the  mouth  to  the  pharynx,  the 
operation  will  have  been  rightly  done;  but  if  it  does  not  descend, 
it  is  clear  that  about  the  ethmoid  bones,  or  the  upper  part  of  the 
nose,  there  are  fleshy  bodies  which  have  not  been  reached  with 
the  polypus  instruments." 

The  Knotted  String  for  Nasal  Polypi. — Then  follows  the  descrip- 
tion of  a  barbarous  method  which,  it  seems  to  me,  Paulus  must 
have  derived  from  a  faulty  reading  or  a  misunderstanding  of  the 
sponge  method  of  Hippocrates.  Certainly  nothing  of  the  kind 
can  be  found  in  the  Hippocratic  treatises,  as  Adams  in  his  com- 
ments intimates,  but  we  shall  subsequently  find  the  Arabians 
sedulously  following  this  plan.  They  apparently  derived  much 
of  their  knowledge  from  Paulus.  "Taking,  then,  a  thread 
moderately  thick,  like  a  cord,  and  having  tied  knots  upon  it  at 
the  distance  of  two  or  three  fingers'  breadth,  we  introduce  it  into 
the  opening  of  a  double-headed  specillum  (probe),  and  we  push 
the  other  extremity  of  the  specillum  upward  to  the  ethmoid  open- 
ings, passing  it  by  the  palate  and  mouth,  and  then  drawing  it  by 
both  hands,  we  saw  away,  as  it  were,  with  the  knots  the  fleshy 
bodies.  After  the  operation,  we  keep  the  opening  separate  by 
means  of  a  tent  resembling  the  wick  of  a  lamp." 

As  for  tonsils^  he  pulled  them  forward  with  a  hook  "and  then 
we  cut  them  out  by  the  root  with  the  scalpel  suited  to  that  hand, 
called  ancylotomns,  for  there  are  two  such  instruments  having 
opposite  curvatures."  He  used  a  tongue  depressor  in  this  operation 
as  well  as  in  that  of  uvulotomy  (1.  c.  sec.  31)  but  he  adopts  Galen's 
caution  not  to  cut  ofi'  too  much  for  fear  of  injuring  the  voice  and 
making  the  patient  liable  to  inflammation  of  the  lungs.  If  the 
patient  refuses  a  cutting  operation  the  redundant  portion  may  be 
removed  by  caustics  applied  by  a  special  instrument,  called 
"  staphylocaustos." 

In  his  comments  upon  the  operation  of  Antyllus  for  tracheotomy 
which  I  have  quoted,  Paulus  makes  it  plain  that  he  himself  was 

1  Book  1,  Sec.  10,  Vol.  I,  p.  14.  ^  gook  VI,  Sec.  25,  Vol.  II,  p.  289. 

^  Book  VI,  Sec.  30,  Vol.  II,  p.  297 


96  THE  ARABIANS 

familiar  with  the  operation,  for  he  says  (1.  c.  see.  33):  "We  jiul^re 
the  wind-pipe  has  been  opened  from  the  air  rushing  through  it 
with  a  whizzing  noise  and  from  the  voice  having  been  lost."  In 
closing  the  wound  he  freshened  the  edges  of  the  transverse  incision 
and  sewed  the  skin,  but  not  the  cartilage,  the  latter  not  being 
divided. 

He  follows  Hippocrates  in  his  treatment  of  fractures  of  the  nose, 
(1.  c.  sec.  91).  We  miss  all  invocations,  incantations,  and  amulets 
from  the  throat  pharmacopoeia  of  iVegineta,  and  he  does  not  lay 
much  emphasis  on  the  Chaldean  prescriptions,  though  they  are 
mentioned  with  approval,^  stercoraceous  drugs  and  the  swallow 
prescription  being  advised. 


THE  ARABIANS. 

In  pursuance  of  the  plan  of  this  book  we  must  now  devote  an 
unusual  amount  of  space  to  the  rapid  enumeration  of  the  political 
events  which  shifted  the  leadership  in  science  and  medicine  from 
the  Greeks  to  the  Arabians,  events  which  are  connecting  links  in 
the  progress  of  civilization. 

Greek  physicians  existed  at  Constantinople  as  long  as  the  Chris- 
tian religion  flourished  there,  but  while  their  works  are  of  interest 
to  the  student  of  the  phenomena  presented  by  a  dying  civilization, 
they  are  of  less  interest  to  the  historian  of  the  progress  of  medical 
knowledge.  Guizot,^  speaking  of  Roman  Gaul  in  the  last  days  of 
the  Empire,  asserted  that  "The  Library  at  Constantinople  had  a 
librarian  and  seven  scribes  constantly  occupied,  four  for  Greek  and 
three  for  Latin ;  they  copied  the  new  works  which  appeared  or  the 
ancient  ones  which  were  degenerating.  It  is  probable  that  the 
same  institution  existed  at  Treves,  and  in  the  larger  cities  of  Gaul." 
Notwithstanding  periods  of  vigor  exhibited  by  the  Eastern  Empire, 
notwithstanding,  as  Freeman  declares,  many  of  th(>  Emperors 
were  great  conquerors  and  rulers  who  beat  back  their  enemies  on 
every  side,  and  made  conquests  in  their  turn,  although  the  last 
Constantine  died  a  death  worthy  of  the  first,  h()])e]essly  battling 
for  his  empire  in  the  breach  of  the  city  wall,  notwithstanding  all 
these  things,  learning  did  not  send  forth  any  new  shoots,  and 
Gibbon  sums  the  matter  up  thus:  "They  read,  they  praised,  they 
compiled,  but  their  languid  souls  seemed  alike  incapable  of  thought 
and  action."  Finally,  their  political  existence  sank  to  the  level 
of  their  civilization.  The  walls  of  Constantinople  protected  its 
feeble  inhabitants,  except  for  its  conquest  by  the  crusaders,  for 
more  than  a  thousand  years  after  its  impregnable  situation  had 

1  Book  III,  Sec.  27,  Vol.  I,  p.  464. 

2  Hist,  de  la  Civilization  en  P>ance. 


THE  ARABIAN  CONQUEST  97 

been  selected  and  its  defences  constrncted  by  the  foresight  and 
energy  of  the  great  Constantine.  At  last  it  fell  (1453)  before  the 
conquering  Turk,  as  falls  every  work  of  man,  however  wisely 
built  or  however  stupendous,  vniless  its  bulwarks  are  the  con- 
tinued energy,  virtue,  and  intelligence  of  the  people  who  enjoy  its 
protection. 

We  have  seen  how,  five  hundred  years  before  the  Christian  era, 
the  great  kings  of  Persia  drew  their  physicians  from  the  Greek 
schools  of  medicine.  The  Alexandrian  dynasties  had  long  since 
passed  away,  and  it  is  significant  to  note  to  how  low  a  level  Greek 
medicine  had  sunk  among  the  bastard  descendants  of  that  noble 
race  to  find  another  line  of  Persian  kings  sending  Arabian  physicians 
to  Constantinople  to  minister  to  the  many  bodily  ills  of  some  of 
the  Greek  emperors;  but  it  was  first  through  Greek  physicians, 
through  the  exiles  whom*  the  fanaticism  of  the  theologians  of 
Constantinople  had  driven  into  Persia,  that  the  Arabs  received 
the  first  inoculation  of  the  virus  of  learning.  It  was  through  the 
exiles  driven  by  anarchy  and  the  forebodings  of  impending  ruin, 
as  well  as  by  its  culmination  that  Italy  first  received  the  direct 
impetus  from  Greek  sources  which  resulted  in  the  Renaissance. 
From  the  Nestorians  the  Arabians  not  only  absorbed  profane 
knowledge,  but  from  them  the  youth  ]\Iohammed  on  his  caravan 
trips  drew  the  inspiration  of  his  religion.  Not  only  the  Nestorians, 
but  still  more  perhaps  the  Jews,  who  taught  their  religion  to  both 
Christ  and  ]\Iohammed,  aided  in  this  transfer  of  learning  to  the 
Arabians. 

The  Arabian  Conquest. — Four  years  after  the  death  of  Justinian, 
^Mahomet,  the  only  son  of  Abdalla,  was  born  at  ]\Iecca  in  569 
A.D.  Heraclius,  after  his  great  victories  over  the  Persians,  was 
weighted  down  by  age  and  disease,  and  his  empire  was  exhausted 
by  years  of  destructive  warfare.  Therefore  the  feeble  races  imder 
the  sway  both  of  the  Persian  and  of  the  Holy  Roman  Empire  of 
the  East  were  easy  conquests  for  the  sturdy  Arab.  The  forces  of 
nature  are  eternal,  their  laws  immutable,  and  the  results  of  their 
activity  when  surveyed  over  long  periods  of  time  and  sufficient 
expanse  of  space,  appear  analogous  even  to  the  finite  understand- 
ing of  man.  The  expansion  of  the  Mohametan  crescent  raj)idly 
grew  until  in  a  period  of  less  than  a  century  from  the  death  of 
Mahomet  in  632  a.d.  one  horn  rested  in  the  fertile  valleys  of  Spain 
(710  A.D.)  and  the  other  menaced  the  walls  of  Constantinople 
itself.  The  fanaticism  which  is  easily  engendered  in  the  populations 
of  Asia  has  made  it  the  cradle  of  religions.  The  poverty  and  hard- 
ships of  the  human  beings  who  struggled  among  the  burning  sands 
of  Arabia  weeded  out  the  weaklings  of  the  race  and  trained  the 
endurance  of  the  survivors  to  resist  the  effects  of  thirst,  hunger, 
and  fatigue,  and  when  fired  by  the  visions  of  ^Mahomet  with  the 
prospects  of  glory  and  power  and  with  the  hope  of  the  indulgence 
7 


98  THE  ARABIANS 

of  libidinous  passions  both  in  this  world  and  the  next,  they  swept 
away  the  feeble  civil  power,  and  with  it  the  babblinc;  theological 
dissensions  of  the  Christians  of  Africa  and  Asia  ^Minor.  crossed 
the  JNIediterranean  and  overwhelmed  the  Goths  who  had  had  time 
to  be  enervated  by  the  luxury  of  the  fertile  plains  of  Andalusia 
and    Granada. 

But  from  the  northeastern  confines  of  the  temperate  zone  in 
Asia,  the  Turks,  having  previously  accepted  the  religion  and 
despised  the  civilization  of  the  followers  of  the  Prophet,  checked 
the  advance  of  his  race.  From  the  northwestern  provinces  of 
Europe  the  Germans  and  Franks,  unsullied  by  a  religion  which 
inculcates  the  righteousness  of  polygamy  and  human  slavery, 
checked  the  advance  of  the  Saracens  at  the  mountainous  line  which 
separates  the  Spanish  peninsula  from  the  rest  of  Europe.  Charles 
Martel  with  his  stout  heart  and  iron  mace  annihilated  their  army 
before  Tours  in  732,  and  e\'entually  they  w^ere  driven  back  beyond 
the  Pyrenees  to  develop  a  wonderful  civilization  and  to  suffer 
from  its  luxury  and  the  enervation  of  the  climate,  which  after 
nearly  eight  hundred  years  made  them  a  prey  to  the  po\\ers  of 
Fredinand  and  Isabella  (1493)  grown  to  an  effecti^'e  force  amidst 
the  more  arid  and  mountainous  regions  of  Aragon  and  Castile.^ 

We  have  cause  to  be  grateful  not  only  that  the  victories  of 
Mahomet  produced  em])ires  which  protected  science  and  letters 
at  Bagdad,  Alexandria,  and  Saragossa,  but  because  they  shattered 
the  belief  of  large  numbers  of  P^uropean  mankind  in  the  vain  and 
presumptuous  claims  of  the  Christian  ecclesiastics  to  a  monopoly 
of  the  favor  of  heaven,  and  so  perhaps  did  something  to  start  the 
idea  that  the  abodes  of  bliss  are  not  exclusively  a  private  park  for 
the  priests  and  their  friends.  At  any  rate  they  must  have  suggested 
the  idea  that  images  and  relics  were  as  little  efficacious  in  ensuring 
victory  as  the  gods  of  the  pagans  over  whose  destruction  the  early 
Christians  gloated. 

The  Destruction  of  the  Alexandrian  Libraries. — Julius  Caesar  had 
first,  by  the  accident  of  war,  caused  the  burning  of  the  Alexandrian 
library  in  the  ^luseum.  This  was  later  replenished  by  Anthony  in 
his  devotion  to  Cleopatra,  at  the  expense  of  the  library  at  Pergamos. 
Four  hundred  years  later  Theophilus,  the  Bishop  of  Alexandria, 
destroyed  also  the  library  in  the  Serapion.  His  nephew,  the  saintly 
Cyril,  followed  him  in  the  bishopric  and  added  further  laurels  to 
the  family  fame  by  killing  the  fair  ITypatia  with  a  club.  She  was 
a  learned  pagan  lady,  addicted  apparently  to  lecturing  on  theosophy. 
Finally  the  remnants  of  the  books  in  Alexandria,  which  had  survived 
the  vicissitudes  of  a  thousand  years,  were  burned  by  the  Arabians, 
when  they  were  fresh  from  the  barbarism  of  the  desert,  Omar 

•  The  Arabs  coiujuered  Persia  in  the  seventh,  Spain  in  the  eighth,  and  ti:e 
Punjaub  in  the  ninth  century,  and  finally  all  India. 


THE  ARABIAN  RENAISSANCE  99 

sending  word  that  what  was  not  contained  in  the  Koran  was  false 
and  what  was  also  to  be  found  in  the  Koran  was  on  that  account 
superfluous.  The  great  temple  of  the  Serapion,  the  annex  to  the 
jNluseum,  where  science  had  flourished  for  centuries,  with  its 
splendid  gardens  of  birds  and  beasts  and  its  laboratories  supplied 
with  its  instruments  of  precision,  were  destroyed  by  the  fury,  the 
folly,  and  the  fanaticism  of  man.  It  has  been  denied  that  the 
Arabians  found  anything  to  destroy.  However  that  may  be,  these 
fiery  fanatics,  intent  on  entering  the  gates  of  Heaven,  filled  with 
objects  of  sensual  delight,  suddenly  developed  such  a  love  for 
material  science  as  the  world  had  never  seen  before  and  perhaps 
has  not  been  familiar  with  since. 

The  Arabian  Renaissance. — As  Draper  says,  the  Byzantines 
obliterated  science  in  theology  and  the  Saracens  illuminated  it 
in  medicine.  Vast  libraries  again  were  collected  at  Bagdad  and 
elsewhere  in  Asia,  Africa,  and  Spain.  The  works  of  Ancient  Greece 
were  translated  into  Syriac  by  the  Jews  and  the  Nestorians,  both 
of  whom,  the  former  for  denying  and  the  latter  for  modifying  the 
Catholic  acceptation  of  Christ,  had  been  persecuted  and  expelled 
from  the  Byzantine  and  Roman  dioceses.  A  good  deal  of  Chaldean 
medicine  was  introduced  by  them  to  the  Arabs  who  were  at  first 
apt  scholars  in  these  matters.  We  have  seen  how  its  amulets  and 
incantations  and  its  filthy  drugs  abounded  in  the  later  Greek 
writers.  ^Yith  these  things,  however,  astrology  and  the  germs  of 
alchemy  were  brought  from  the  plains  of  Asia,  and  out  of  these 
aided  by  the  traditions,  if  not  the  records,  of  the  school  of  Alex- 
andria the  Arabs  developed  the  great  sciences  of  astronomy  and 
chemistry.  While  they  soon  rejected  with  contempt  the  belief 
in  incantations  and  amulets,  they  persisted  in  the  use  of  stercor- 
aceous  drugs.  Unfortunately  for  medicine  they  neglected  the 
study  of  anatomy  through  the  dissection  of  the  human  body. 
In  this  fact  we  recognize  the  influence  of  their  religious  scruples 
in  preventing  any  material  advance  of  rational  medicine  over  the 
teachings  of  Galen  and  Hippocrates;  for  without  this  underlying 
study,  medical  science  comes  to  a  standstill  and  will  ultimately 
perish  entirely,  however  enlightened  its  votaries  may  be  in  other 
directions.  Indeed,  whatever  may  have  been  their  contributions 
to  other  sciences,  I  confess,  after  reading  something  of  Arabian 
medicine,  to  have  been  neither  edified  nor  impressed.  It  would 
seem  that  in  six  hundred  vears  thev  miglit  lla^■e  done  more  when 
we  consider  the  six  hundred  years  which  elapsed  between  Hip- 
pocrates and  (ralen.  We  look  in  ^•ain  for  any  material  advance 
in  the  knowledge  of  the  nose  and  throat  and  their  diseases  made 
by  the  Arabs.  It  is  to  them,  however,  we  owe  the  introduction 
into  our  pharmacopeia  of  the  syrups  and  elixirs,  so  useful  in 
aft'ections  of  the  throat  as  vehicles  for  drugs  administered  in  them, 
which  often  derive  from  the  vehicle  an  ephemeral  reputation. 


100  THE  ARABIANS 

The  Inferior  Maxilla. — It  will  be  remembered  that  Galen  supposed 
the  inferior  maxillary  bone  was  not  a  single  bone,  but  composed 
of  two  hahes.  This  error,  accordinfj;  to  Sprengel,  was  pointed 
out  by  AbdoUatif,  who  made  the  discovery  ])y  examining  with 
care  one  of  the  many  heaps  of  human  bones  which  were  so  j)lentiful 
in  tlie  days  when  religion  was  propagated  with  sword  and  fire; 
and  this  was  almost  the  extent  of  their  contribution  to  the  anatomy 
of  the  head  and  neck.  They  were  familiar  with  uvulotomy  and 
tonsillotomy  and  the  removal  of  nasal  polypi  l)y  the  barbarous 
string  method  of  Paulus  Aegineta,  ]\Iesua  using  horse  hairs  twisted 
into  a  knotted  string  for  the  purpose.  Rhazes,  also  an  early  Arabian 
writer  (died  923  a.d.),  was  familiar  with  these  methods. 

Tracheotomy. — Tracheotomy  was  known  to  them  only  from 
Aegineta's  description  of  Antyllus'  o})eration.  Even  Albucasis, 
a  late  (died  1122)  and  perhaps  the  boldest,  certainly  the  most 
brutal,  of  the  Arabian  operators,  knew  of  no  one  in  his  time  who 
had  performed  it.  He  had  seen  a  nurse  girl  who  had  cut  her  wind- 
pipe and  who  had  completely  recovered  when  he  sewed  up  the 
wound.  iVvicenna  (980-1036),  the  Prince  of  Physicians  and  the 
greatest,  of  the  Arabian  authors,  simply  describes  the  operation 
according  to  Paulus,  while  Avenzoar  (died  1161)  went  so  far  as 
to  try  it  on  a  goat.  Avicenna,  and  many  others  of  the  Arabian 
writers,  showed  they  w-ere  practical  observers  in  likening  some  of 
the  nasal  polypi  to  hemorrhoids  and  advising  the  ligature  for 
them.  In  this  they  were  followed  by  many  of  the  writers  of  the 
Italian  Renaissance  and  even  of  much  later  times.  A\-icenna,  whose 
work  was  a  text-book  of  almost  exclusive  authority  during  the 
later  ]\Iiddle  Ages,  describes  the  anatomy  of  the  nose  and  throat 
in  a  very  poor  transcription  of  Galen.  He  gives,  however,  a  very 
good  description  of  the  disturbances  of  olfaction,  recognizing  the 
two  varities,  viz.,  obstructive  anosmia  due  to  nasal  stenosis  and 
the  essential  form  due  to  some  central  brain  lesion.^ 

The  Cautery. — The  use  of  the  cautery,  carried  to  such  great 
extremes  by  Albucasis,  was  a  favorite  remedy  for  all  sorts  of 
affections.  Baas  relates-  how  ]\Iahomet,  instead  of  resorting  to  a 
more  spiritual  and  miraculous  method,  advised  a  friend  suffering 
from  angina  that  he  should  have  an  application  made  of  the  actual 
cautery.  Johannus  Mesua  Damascenus  advised''  the  use  of  forceps 
for  the  removal  of  ])olypi  and  afterward  the  cauterization  of  their 
roots,  or  else  the  use  of  hot  forceps,  but  if  this  method  was  im])os- 
sible  he  used  the  horse-hair  string.  In  this  author  we  may  find  this 
remarkable  reconnnendation  for  the  cure  of  inflannnation  of  the 
palate.'*    "  The  second  method  of  cure  is  the  diversion  of  the  cause, 

1  Edit:   Venice,  l.%2,  f.  581  et  seq. 

2  History  of  Medicine,  N.  Y.,  1889,  p.  219. 

'  Lib.  II,  De  Aegritud.  Nariuin,  Cap.  G,  Opera,  Venice,  1,589,  p.  231. 
^  Opera,  Lib.  II,  p.  238.     Lib.  II,  Sect.  II— Summa  1,  Cap.  2. 


NASAL  SPECULUM  101 

and  this  is  performed  in  a  manner  which  causes  the  trouble  to 
shift  its  seat,  in  short  rubbing  of  the  ears  and  pulHng  them  forcibly 
upward,  and  the  painful  stretching  of  them,  and  the  application  of 
cups  to  the  opposite  part.  For  these  things  raise  the  inflammation 
and  bear  it  upward;  and  among  those  things  which  are  usefid  in  the 
elevation  of  it  is  that  a  handful  of  hair  should  be  grasped  in  the 
hands  and  the  patient  told  to  keep  silent.  Then  put  thy  feet  on 
his  shoulders  and  drag  strongly  on  the  handful  of  hair,  until  the 
skin  is  pulled  up,  for  by  such  dislocation  will  the  pharyngitis  also 
be  raised."  These  patients  probably  complained  as  do  our  own 
that  their  "palates  were  down." 

Some  confusion  exists  among  the  Arabians  as  to  whether  the 
dung  of  a  white  dog  or  the  white  dung  of  a  dog,  to  be  ol)tained  by 
feeding  him  on  bones,  was  the  proper  medicament  in  angina.  The 
swallow  prescription  is  always  mentioned  in  some  form. 

In  removing  foreign  bodies  from  the  throat  Janus  Damascenus 
recommends,  apparently  as  a  variation  of  the  sponge  method  we 
have  noted  in  Aetius,  the  tying  of  a  piece  of  half-cooked  meat  on  a 
string  and  bringing  it  up  after  it  is  swallowed.  Nearly  all  even  of 
this  sort  of  surgery  may  be  found  among  the  late  Greek  writers  of 
the  Eastern  Empire. 

Nasal  Speculum. — Guy  de  Cauliac^  refers  to  Haly  Abbas  using 
"un  instrument  appelle  mirror  an  soleil"  or  in  the  Latin  edition 
"speculum  ad  solem,"  for  opening  the  nostrils  in  examining  a 
nasal  growth.  On  referring  to  the  Latin  translation  of  Haly  Abbas 
by  Michael  de  Capella  in  1523,^  it  may  be  seen  that  the  passages 
to  which  Guy  apparently  refers  hardly  warrant  this  rendering. 
In  the  work  of  Constantine  the  African,  "De  Communibus 
Medico  Cognitu,"  which  is  said  to  be  an  abridgement  of  Haly 
Abbas,  nothing  of  the  kind  is  to  be  found.  We  may  conjecture 
that  Cauliac  read  the  text  wrongly  or  that  he  had  access  to  others 
which  are  not  now  accessible  to  us;  Init  at  anv  rate  it  is  evident 
that  Cauliac  had  some  knowledge  of  such  an  instrument.  Indeed, 
the  use  of  the  cautery  in  the  nose  from  the  time  of  Hippocrates  to 
the  present  presupposes  the  use  of  a  tubular  speculum  at  least.^ 

From  the  fact  that  the  processes  are  occasionally  multiple  with 
a  common  base  of  attachment  and  the  Greek  conception  of  them 
was  eml)odied  in  the  name  polypus  or  many  feet,  we  find  the 
medieval  translations  from  the  Arabic  converting  the  name  into 
the  word  "Scorpio."  How  accurately  this  expresses  the  Arabic 
word  for  polypus,  I  do  not  know. 

Albucasis  who  used  the  cauterj'  savagely  for  almost  everything 

1  Edit:   Nicaise,  Paris,  1890,  p.  328. 

2  Liber  Totius  Med.,  Lugduni,  ir)2;5.    Lilier  IX,  Cap.  ;}2,  f.  279,  Col.  C. 

'  According  to  Cloquet  the  speculum  of  Ciuy  de  Cauliac,  or  Haly  Abbas,  is 
figured  in  L'lntcrpretations  des  Dictions  Chirurgicales  which  Laurent  Joubert 
printed  at  the  end  of  his  edition  of  the  (Irande  Chinn-gie  de  Guy  de  Chauliac, 
printed  at  Rouen  in  Kilo. 


102  THE  ARABIANS 

and  apparently  often  at  random,  recommends  burning  tlie  skin 
beneath  the  eyebrows  for  a  bad  odor  from  the  nostrils.^  We  may 
conjectnre  that  this  is  related  to  the  Libyan  custom  as  related  by 
Herodotus  (1.  c.)-  Some  of  the  remarks  of  Albucasis  in  regard  to 
operations  on  the  nose  and  throat  may  be  inserted  here  as  inter- 
esting and  illustrating  somewhat  the  figures  of  the  instruments 
taken  from  Channing's  Latin  version  of  his  Surgery.  The  existence 
of  these  figures  in  the  original  manuscript  was  one  of  the  fore- 
runners of  the  introduction  of  wood-cuts,-  which  antedated  the 
invention  of  Guttenberg.  It  mnst  be  confessed  that  Channing's 
Latin  text  of  Albucasis  does  not  clearly  correspond  with  the  figures 
which  accompany  it. 

Tonsillotomy. — "And  when  glands  occur  in  the  throat  similar  to 
the  glands  wliich  occur  externally,  they  are  called  the  two  tonsils. 
When  thou  hast  treated  them  with  those  things  which  1  have 
mentioned  and  they  are  not  cured,  look  and  if  the  tumor  is  hard 
and  of  a  dark  color,  of  slight  sensibility,  do  not  touch  them  with 
the  knife.  And  if  it  is  of  a  red  color  and  the  base  is  broad  do  not 
touch  it  with  a  knife  for  fear  of  hemorrhage,  but  delay  until  it 
has  ripened,  for  then  thou  canst  perforate  it  or  it  will  break  of 
itself.  But  if  it  is  of  white  color,  round  and  has  a  slender  base,  this  is 
the  kind  Avhich  is  suitable  and  thou  shouldst  cut  it.  Thou  shouldst 
examine  before  operation  if  the  swelling  has  entirely  disappeared 
or  in  what  manner  it  has  diminished.  Then  thou  seatest  the  patient 
in  the  clear  sunlight  and  takest  his  head  in  thy  lap  and  openeth 
his  mouth  and  taketh  the  instrument  in  thy  hands  which  will 
depress  his  tongue,  a  concave  instrument  somewhat  of  this  form 

Fig.  6 


(Fig.  6);  thou  canst  make  it  of  silver  or  of  brass;  it  should  be  thin 
like  a  knife;  with  this  the  tongue  is  depressed  and  the  swelling  will 
be  ai)parent  to  thee,  and  let  thy  vision  fall  upon  it.  Then  thou  shalt 
take  a  hook  and  fix  it  in  one  tonsil,  and  with  it  thou  shalt  draw 
it  out  as  far  as  possible;  but  of  course  thou  shalt  not  draw  out  with 
it  any  of  the  membranes.  Then  thou  shalt  incise  it  with  an  instru- 
ment of  this  form  (Fig.  7).  It  is  similar  to  a  forceps  except  that 
the  ends  are  curved  and  the  edge  of  each  is  opi)osite  the  other  and 
is  very  sharp.     It  is  made  from   Indian  or  fine  Damascus  iron. 

1  Albucasis  de  Chiriirgia:  cura  J.  Channing,  Oxonii,  1778,  I,  p.  35,  Sec.  XIV. 

2  The  earliest  wood-cut  roinaininp;  to  us  dates  from  1423,  but  there  is  ample 
evidence  of  the  existence  of  the  art  long  before  this,  in  Venice  and  elsewhere. 


A  POSTNASAL  TUMOR  103 

But  if  this  instrument  is  not  at  hand  thou  mayst  cut  it  with  a 
knife  with  this  shape  (Fig.  8) — sharp  on  one  side,  less  so  on  the 
other.  And  sometimes  other  tumors  than  tonsils  grow  in  the 
mouth.  Thou  wilt  cut  these  out  as  thou  doth  the  tonsils."  (Liber 
II,  sec.  36.) 


Fig.  7  Fig.  S 

c        


i) 


A  Postnasal  Tumor. — In  short,  they  were  to  be  cut  out  with 
scissors  or  a  sickle-shaped  knife.  Then  follows  the  very  interesting 
report  of  a  postnasal  growth.  "Once  I  treated  the  tumor  of  a 
woman  which  had  grown  in  her  throat.  It  was  of  a  dusky  color 
and  not  very  sensitive.  The  woman  was  almost  strangled,  and 
from  the  constriction  of  the  passage  breathed  with  difficulty,  and 
she  was  prevented  from  drinking  or  eating  anything,  so  that  she 
was  reduced  almost  to  the  point  of  death,  and  she  had  been  in 
this  condition  a  day  or  two.  The  tumor  so  projected  forward 
that  two  branches  of  it  protruded  from  the  nostrils.  Therefore 
W'ith  the  greatest  promptitude  I  hastened  to  fix  in  one  of  these 
a  hook  and  dragged  on  it,  and  that  whole  portion  was  pulled  forward. 
Then  I  cut  it  off  where  I  had  pulled  it  out  at  the  nostrils.  Then 
I  did  the  same  for  that  which  projected  on  the  other  side.  Then  I 
opened  her  mouth  and  depressed  her  tongue.  Then  I  fixed  a  hook 
in  the  tumor  itself  and  cut  off  a  part  of  it  and  only  a  little  blood 
came  from  it,  and  the  throat  of  this  woman  was  free  and  she 
immediately  drank  water.  Then  I  offered  her  some  food.  I  did 
not  cease  to  cut  pieces  from  this  tumor  for  a  long  time,  but  the 
new  growth  filled  the  place  of  the  excised  pieces  until  her  patience 
and  my  own  were  exhausted.  Wisely  then  did  I  act,  and  I  cauter- 
ized the  tumor  up  in  the  back  of  her  throat  and  thereupon  it  did 
not  recur.  Then  the  woman  left  me  and  I  know  not  what  God 
did  with  her  after  me."  These  quotations,  as  literal  as  possible, 
from  Channing's  deplorable  Latin,  will  indicate  the  manner  of 
man  this  modest  Arab  was,  and  better  than  words  of  mine  will 
portray  the  state  of  laryngological  practice  among  the  Arabs, 
It  may  be  profitably  compared  with  the  procedures  of  Hippocrates 
in  cases  of  nasal  polypi,  in  order  to  realize  the  backward  steps 
taken  in  1500  years.  Albucasis  describes  about  the  same  methods 
of  treatment  for  uvulotomy,  following  the  injimctions  of  Galen. 
His  directions  for  removing  foreign  bodies  are  much  the  same  as 
those  of  the  later  Greeks.  His  remarks  on  laryngotomy  I  have 
referred  to  above.  Love  of  the  hot  iron  and  dread  of  the  knife 
characterized  Arabian  surgery,  and  they  seemed  more  afraid  of 
drawing  blood  than  of  infiicting  atrocious  pain.  In  all  this  we 
behold  the  result  of  defective  anatomical  knowledge. 


104  THE  PRE -RENAISSANCE  PERIOD 

And  these  were  the  votaries  of  science  who  guarded  the  portals 
of  medicine  for  six  hundred  years.  In  other  departments  doulitless 
their  achievements  were  great,  but  despite  tlie  great  debt  modern 
civiUzation  owes  to  them,  medical  knowledge  languished  and  we 
have  only  to  be  thankful  that  it  did  not  entirely  expire,  that  it 
was  not  wholly  given  up  to  amulets  and  charms  and  stercoraceous 
drugs,  that  mysticism  and  the  occult,  which  we  still  ha\e  with  us 
in  the  Faith  Cure  and  the  ]Mind  Cure  and  all  that  foul  brood  of 
Darkness,  did  not  in  this  period  of  weakness,  when  anatomy  had 
perished  entirely,  overwhelm  the  Art  of  ]\Iedicine  as  it  did  in 
India.  The  spectre  Orientalism  still  haunts  us.  It  is  a  vague 
disembodied  spirit,  but  it  is  the  ever-present  foe  of  civilization. 

For  several  centuries  it  was  through  the  Arabs  only,  or  ])crhaps 
it  is  better  to  say,  chiefly,  that  Europe  knew  anything  of  the  medi- 
cine of  Hippocrates  and  Galen,  but  when  the  better  editions  of 
the  early  Greek  writers  came  into  the  possession  of  the  Italians, 
it  was  soon  perceived  how  gross  had  been  their  rendering  of  them. 


THE  PRE-RENAISSANCE  PERIOD. 

To  the  superficial  reader  of  mediaeval  history  the  causes  of  the 
Renaissance  may  seem  mysterious  and  puzzling.  It  requires,  how- 
ever, only  a  moderate  amount  of  reflection  and  study  to  under- 
stand that  the  infusion  of  the  vigorous  new  northern  blood  into 
that  which  flowed  in  the  veins  of  the  old  races,  dwelling  around 
the  Mediterranean,  produced  a  new  and,  from  the  cross-breeding, 
a  more  vigorous  race  of  men.  Amid  the  ruins  of  Rome,  ignorance, 
superstition,  and  fanaticism,  the  interminable  wars,  the  terrible 
devastating  plagues  had  induced  a  gro\'eling  misery  and  a  poverty, 
for  many  ages  foreign  to  the  sunny  slopes  of  the  Cis-Alpine  hills 
and  fertile  valleys  of  Italy.  The  primeval  forces  of  Nature  thus 
working  through  evolutionary  laws  again  produced  in  this  garden 
spot  of  the  world  a  race  of  men  from  which  the  weak  in  bod}'  and 
mind  had  been  weeded  out.  The  soil  was  rij)e  for  the  seeds  wafted 
from  other  civilizations  now  rapidly  approaching  collapse. 

Learning  in  the  Middle  Ages. — Daremberg^  does  not  succeed  in 
convincing  us  that  much,  if  anything,  that  may  be  called  medical 
learning  really  was  to  be  found  in  Europe  in  that  period  which 
lies  between  the  deluge  of  the  barbarians  from  the  north  and  the 
introduction  of  Arabian  science.  The  ruthless  hand  of  Gregory 
the  Great  (Pope  59(H54())  had  long  since  demolished  the  library 
on  the  Capitoline  Hill  which  the  munificence  of  Augustus  had 
founded.  His  motto:  "Ignorance  is  the  mother  of  devotion," 
supplied  tlicn  a  sufficient  defence  as  it  now  furnishes  an  ample 

1  Hist,  des  Sciences  Mtd.,  Paris,  1870,  Vol.  I,  p.  277. 


INFLUENCE  OF  ARABIAN  SCIENCE  105 

explanation  of  the  deed.  He  himself  was  one  of  the  most  learned 
men  of  his  times,  but  the  intellectual  treasures  of  the  Ancient 
World  had  been  lavished  on  his  barbarian  soul  in  vain.  Some 
manuscripts,  it  is  true,  with  other  weaklings  had  found  a  refuge 
in  the  hidden  recesses  of  the  cloisters  of  sordid  monks,  who  sought 
as  eagerly  for  safety  in  this  world  as  for  Paradise  in  the  next,  but 
these  manuscripts  escaped  rather  through  the  negligence  than  the 
respect  of  the  priestly  rabble.^  Famous  schools,  it  is  true,  existed 
at  Monte  Cassino,  Amalfi,  Naples,  and  Salerno  during  the  ^Middle 
Ages,  but  what  their  learning  consisted  of  it  is  impossible  to  know. 
Professor  Ordronaux's  elegant  edition  of  the  Regimen  Salernitanum 
gives  a  hint  of  it  in  many  places.  We  may  easily  form  a  picture 
of  a  circle  of  lusty,  merry,  dirty  monks  sitting  around  a  rough 
table,  and  with  beer  mugs  and  drinking  horns  held  on  high  roaring 
forth  the  refrain: 

"Si  tibi  serotina  noceat  potatio  vini 
Hora  matutina  rebibas,  et  erit  medicina." 

Influence  of  Arabian  Science. — The  origin  of  the  School  of  Salerno 
is  unknown,  but  there  is  little  doubt  that  such  learning  as  there 
existed  was  derived  through  the  Jews  and  possibly  through  other 
sources  from  the  Arabians.  It  was  there,  or  at  Monte  Cassino 
(1086),  that  Constantine,  an  African  prelate,  after  a  sojourn  of 
thirty-nine  years  among  the  Arabians,  where  he  is  said  to  have 
been  a  pupil  of  Avicenna,  wrote  his  plagiaristic  works  which  he  did 
not  dare,  and  perhaps  did  not  wish,  to  credit  to  the  pagans,  Hip- 
pocrates, Galen,  Avicenna  and  Haly  Abbas,  from  whom  everything 
in  them  of  value  was  miserably  transcribed.  By  such  means,  at 
first  secretely,  then  openly,  the  knowledge  of  the  Arabs  found  its 
way  into  Europe  through  Italy  and  Spain,  and  this  process  was 
greatly  facilitated  by  a  few  enlightened  individuals,  who,  like 
Constantine,  had  spent  their  youth  at  the  courts  of  the  Arabian 
monarchs. 

Averrhoes  introduced  skepticism,  "le  flambeau  de  la  science," 
as  some  Frenchman  calls  it,  to  the  Arabians  and  was  duly  hated 
by  the  ^Mahometan  and  Christian  dogmatist  alike,  })ut  this  was  a 
mere  undercurrent  in  Christian  Europe  for  a  long  time,  too  feeble 
to  be  perceived  amidst  the  robust  but  groveling  superstition  of 
the  times.  Pope  Sylvester  II  had  been  educated  at  Cordova, 
spoke  Arabic  like  a  Saracen,  and  had  been  elevated  (999  a.d.)  by 
the  politics  of  the  time  to  the  chair  of  St.  Peter  as  a  creature  of 
the  Emperor  Otto  HI.     The  influence  of  the  Arabians  on  the 

'  Daremberg:  Hist,  dcs  Sciences  Med.,  Vol.  I,  p.  25G,  quotes  from  a  mediaeval 
author  as  follows: 

C'lerici  nostri  tciiiporis  polius  sequntur  scholas  Antc-Christi  quam  Christi, 
potius  dediti  gula;  (|uain  glossa;:  potius  coUiguiit  libras  quam  leguiit  librcs; 
libentius  imitantur  Martham  quam  Mariam. 


106  THE  PRE-RENAISSANCE  PERIOD 

science  of  the  ^Middle  Ages  may  be  strikingly  witnessed  in  the 
Inferno  of  the  pious  Dante  where  Hippocrates  and  Galen  are 
joined  to  the  shades  of  Avicenna  and  even  to  that  of  the  hated 
Averrhoes.  (Canto  IV  L,  144.)  There  is  a  curious  observation 
to  be  made  casually  in  reading  Kassel's  excerpts  from  Averrhoes 
which  gives  one  a  hint  of  the  mental  vigor  of  the  Arabian,  who 
excited  the  execration  of  the  churchman  and  earned  a  warm  place 
in  the  Inferno  of  Dante  for  himself  by  his  skepticism. 

Speaking  of  the  five  senses,  he  declares  that  animals  diiler  from 
men  in  the  fact  that  some  of  them  can  smell  without  possessing 
the  organ  for  that  sense,  this  being  the  case  with  bloodless  organisms. 
In  other  words,  this  free  thinker,  Averrhoes,  accepted  the  testimony 
of  observation  even  though  it  went  against  the  (Talenic  and  Hip- 
pocratic  acceptation  that  for  voice  production  we  must  have  an 
instrumentum  vocis,  for  smelling  an  "instrumentum  odoratum." 
This  is  the  essence  of  scientific  thought,  this  is  the  spark  that  made 
the  conflagration  in  Christendom  later.  It  has  taken  nearly  a 
thousand  years  to  make  it  a  familiar  thing  to  scientific  men  that 
bloodless  things,  like  some  spiders,  can  smell  with  their  whole 
bodies  even  though  they  have  no  nose,  but  A\errhoes  stands 
alone  in  the  Arabian  civilization.  If  it  had  lasted  longer  he  might 
have  had  associates.  It  is  gratifying  to  be  able  to  pick  out  even 
in  our  subject  this  live  thing  in  the  dead  mentality  of  mediaeval 
thought,  one  of  the  things  that  earned  A\errhoes  a  place  in 
Hell.i 

Influence  of  the  Church. — Neverthless,  as  Guizot  says,  it  is  difficult 
to  imagine  what  would  have  happened  after  the  downfall  of  the 
Roman  Empire  in  Europe  if  the  Christian  Church  had  not  been 
organized.  It  stepped  in  first  as  the  handmaid  and  then  as  the 
mistress  of  the  civil  power,  and  thus,  by  furnishing  some  sort  of 
authority,  having  its  real  foundation  deep  in  the  souls  and  super- 
titions  of  men,  brought  order  out  of  chaos.  It  was  Gregory  the 
Great  who  was  active  in  the  destruction  of  learning  in  Italy,  but 
who  nevertheless  was  a  great  power  of  cohesion  where  all  things 
tended  to  disruption.  Gregory  VII  was  the  great  Ilildcbrand 
who,  when  elected  pope,  substituted  ecclesiastical  for  imperial 
tyranny,  and  in  1077  King  Henry  of  Germany  waded  barefooted 
through  the  snow  of  the  Alps  to  humble  himself  at  the  feet  of  the 
pope  at  Canossa.  Again,  the  civil  power  gained  the  ascendancy 
under  that  liberal  man  of  genius,  Frederick  II  (1194-1250),  king 
of  the  two  Sicilies,  who  had  imbibed  much  learning  and  freedom 
from  superstition  by  his  Arabian  education  and  affiliations.  He 
rendered  the  greatest  service  possible  to  the  art  of  medicine  by 
his  decree  ordering  the  dissection  of  the  human  body. 

'  For  an  account  of  Averrliocs  and  his  works  by  a  synipatlictic  critic,  see 
R^nan;  Averroes  et  TAverroismc. 


INFLUENCE  OF  THE  CRUSADES  107 

Influence  of  the  Greeks. — As  has  been  said,  Greek  men  of  learning, 
rats  from  a  sinking  ship,  flocked  into  Italy  with  their  precious 
manuscripts  from  Constantinople,  many  coming  before  the  crisis 
and  many  escaping  at  the  final  shipwreck  in  1453.  They  found 
for  themselves  and  their  learning  an  asylum  in  Italy,  where  the 
great  families  of  the  Medici,  the  Farnese,  the  Este,  the  Colonna, 
the  Gonzaga,  enriched  and  enlightened  for  the  most  part  by  mari- 
time trade,  and  urged  by  the  influence  of  Petrarch,  gave  them  a 
welcome  and  an  enthusiastic  reception  which  fanaticism  had  denied 
the  Arabians.  But  Petrarch's  welcome  extended  rather  to  other 
branches  of  letters  than  to  medicine,  whose  practitioners  he  lashed 
with  a  fierce  satire  from  which  ^Nloliere  later  drew  his  inspiration. 
A  hundred  years  before  the  fall  of  Constantinople,  on  hearing  of 
the  loss  at  sea  of  a  vessel  carrying  a  valued  and  a  learned  Greek 
friend,  Petrarch's  first  thought  was  to  inquire  if  perchance  the 
surviving  sailors  had  not  saved  some  Greek  or  Latin  manuscripts 
which  might  have  been  among  his  effects. 

It  has  been  noted  that  from  the  time  of  our  first  knowledge  of 
the  School  of  Salerno  to  this  epoch  medical  learning  was  derived 
almost  wholly  from  Greek  sources  through  the  Arabians.  This 
pre-Renaissance  period  of  perhaps  300  or  400  years  includes  Henri 
di  ]Mondeville,  Mondino  di  Luzzi,  Guy  di  Cauliac,  Arnold  di 
Villanova,  Petrus  d'Abano,  Brunus,  and  others,  the  first  fruits 
of  the  seeds  of  learning  of  modern  Europe  from  the  old  stock  of 
Hippocrates  and  Galen. 

Influence  of  the  Crusades. — Even  the  most  cursory  review, 
such  as  this  professes  to  be,  of  the  salient  influences  in  the  spread 
of  knowledge  cannot  ignore  the  crusades.  As  two  thousand  years 
previously  the  Grecian  hosts  are  said  to  have  attacked  the  walls 
of  Troy,  the  holy  city  of  Jerusalem  was  the  scene  of  another 
furious  onslaught  of  western  brute  strength  on  an  eastern  metropolis. 
Homer  draws  a  more  artistic  and  vivid  but  no  more  fearful  picture  of 
the  sack  of  Troy  than  later  historians  drew  of  the  capture  of  Jeru- 
salem by  the  crusaders.  Returning,  if  his  thirst  for  blood  and 
holy  relics  was  not  satiated,  the  crusader  at  least  brought  with 
him,  as  doubtless  did  the  ancient  Greeks,  more  enlightenment 
than  he  set  out  with.  The  survivors  of  the  mighty  hosts  brought 
with  them  back  to  their  homes  not  only  the  bones  of  the  saints 
and  the  splinters  of  the  true  cross,  but  a  broadened  knowledge  of 
men  and  things.  The  aggregations  of  such  large  bodies  of  men, 
under  the  necessity  of  acting  more  or  less  harmoniously,  laid  the 
foundation  for  the  spontaneity  with  which  various  movements  of 
European  social,  political,  and  religious  activity  subsequentlj' 
occurred.  Different  nations  and  different  conditions  of  men 
became,  to  some  extent,  mutually  heli)ful  in  their  \arious  struggles 
toward  liberty  with  that  ecclesiasticism  which  had  fattened  on 
their  estates  and  their  temporal  power  during  the  absence,  which 
the  priests  had  urged  upon  them. 


108  THE  PRE-RENAISSANCE  PERIOD 

Italian  Science. — "The  eagerness  with  which  the  Arabians  had 
collected  the  medical  works  of  the  Ancients  hardly  surpassed  the 
zeal  with  which  the  Italians  of  the  Fifteenth  Century  pursued  the 
same  course,  and  Cosmo  ^Medici  may  be  compared  in  this  respect 
with  Khalif  ^Mamun,  but  let  us  mark  the  difference.  The  Arabians 
translated,  they  often  even  destroyed  the  originals,  and  their  own 
ideas  so  permeated  the  results  that  they  theosophized  Aristotle, 
turned  astronomy  into  astrology  and  made  use  of  tiiese  in  medicine. 
The  Italians  on  the  other  hand  read  and  learned.  The  true  Aristotle 
eventually  crowded  out  the  Arabian/  out  of  the  unaltered  writings 
of  the  Ancients  they  learned  their  Science,  Geography  directly 
out  of  Ptolemy,  liotany  out  of  Dioscorides,  the  Science  of  ^Medicine 
out  of  Galen  and  Hippocrates."^ 

The  Ancients  not  only  supplied  them  with  knowledge  as  they 
did  the  Arabians,  but  they  inspired  them  with  such  a  thirst  for  it 
that  their  own  authority  in  science  was  soon  destroyed,  something 
which  had  never  happened  wath  the  Arabs.  The  popes  and  the 
clergy  in  fostering  at  first  these  beginnings  of  intellectual  life  were 
conjuring  up  genii  which  in  a  few  centuries  were  to  rob  them  of 
all  but  a  vestige  of  their  power,  riches,  and  veneration.  It  is  this 
progressiveness  which  in  medicine  distinguished  the  European 
from  the  Arabian  civilization. 

Although  the  Greek  physicians  from  Constantinople  brought 
their  language  and  their  manuscripts,  they  themselves  had  perhaps 
directly  little  influence.  Their  scientific  attainments  were  insig- 
nificant as  compared  to  the  Arabians.  They  were  the  unworthy 
custodians  of  the  relics  of  a  former  civilization,  the  puny  descend- 
ants of  a  once  vigorous  race.  They  were  full  of  lies,  superstition, 
and  effrontery,  and  they  imposed  on  the  credulity  of  those  still 
more  benighted  than  themselves,  if  we  are  to  believe  what  Petrarch 
says  of  them.  "To  lie  like  a  doctor,"  he  declares  was  a  proverb 
in  his  day.  This  depravity  is  easily  perceived  in  the  counsels  of 
worldly  wisdom,  which  the  pre-Renaissance  medical  writers  scattered 
so  plentifully  through  their  works.  Henri  di  jNIondeville  or  Her- 
mondeville  in  the  frank  discourse  of  his  surgery  is  very  amusing, 
but  he,  quite  as  much  as  Boccacio  (b.  1313)  and  later  Benvenuto 
Cellini  (b.  1500),  displays  the  general  disregard  of  ethical  or  moral 
considerations  in  his  relations  to  his  patients  and  confreres. 

In  the  history  of  medicine,  keeping  step  as  it  does  with  the 
history  of  civilization,  it  is  a  long,  dreary  stretch  of  a  thousand 
years  from  the  sack  of  Rome  by  the  Vandals  (455)  to  the  fall  of 
Constantinople  by  the  Turks  (1453),  and  even  Sprengel,  the  most 

'  Guizot  (Hist,  de  la  Civilization  en  France.  Edit.  16,  T,  12,  ]).  182)  asserts 
positively  that  the  knowledge  of  Aristotle  was  not,  during  the  Middle  Ages, 
derived  exclusively  from  Arabian  sources.  Alcuin  did  much  in  the  time  of 
Charlemagne  to  keep  alive  the  acquaintance  of  the  learned  with  the  works  of 
the  Ancients. 

2  Ranke:  Geschichtc  dcr  Piipste,  Bd.  I,  Cap.  2. 


SQUINANTIA  109 

phlegmatic  of  historians,  breaks  into  paeans  of  rejoicing  when  he 
arrives  at  the  Renaissance.  In  medicine  this  properly  begins  with 
Berengarius,  or  Berengar  del  Carpi,  but  there  is  a  pre-Renaissance 
period,  to  which  I  have  referred  above,  which  it  will  be  interest- 
ing to  glance  at  for  information  as  to  the  nose  and  throat. 

The  School  of  Salerno. — Among  the  Salernitan  verses  from  Prof. 
Ordronaiix's  translation  we  may  select  "De  Raucidine  Vocis"  or 
Hoarseness : 

"Oil  and  raw  apples,  nuts  and  eels,  'tis  said 
With  such  catarrhs  as  settle  in  the  head, 
And  leading  to  a  long  intemperate  course 
Of  life,  will  render  any  person  hoarse." 

And  the  cure  for  it  is 


"Fast  well  and  watch.     Eat  hot  your  daily  fare. 
Work  some  and  breathe  a  warm  and  humid  air; 
Of  drink  be  spare;  your  breath  at  times  suspend, 
These  things  observe  if  you  your  cold  would  end." 

"Si  fiuat  ad  pectus,  dicatur  rheuma  catarrhus, 
Ad  fauces  bronchus;  ad  nares  esto  coryza." 

It  is  singular  that,  in  quoting  from  the  school  of  Salerno,  we  so 
frequently  offer  evidence  of  their  convivial  habits,  snugly  ensconced 
as  thev  were  in  their  cloisters  sheltered  somewhat  from  the  stormy 
experiences  so  abundantly  detailed  in  mediteval  history.  Johannus 
Platearius^  (1225?)  relates  that  his  father  cured  a  "certain  Salerni- 
tan who  was  playing  at  dice,  and  suddenly  felt  that  he  was  attacked 
by  'squinantia.'  When  he  began  to  be  suffocated  and  had  showed 
the  painful  place  with  his  finger,  as  he  was  unable  to  speak,  my 
father,  of  blessed  memory,  a  remedy  having  come  to  his  mind, 
placed  a  wedge  between  the  patient's  teeth,  and  forced  into  his 
throat  a  piece  of  wood  and  the  skin  of  the  aposthume  was  ruptured, 
and  thus,  blood  flowing  in  great  quantity,  he  was  relieved." 

"Squinantia." — Apropos  of  this  word  "squinantia,"  we  may 
note  an  instance  of  transformation  through  the  vicissitudes  of 
time,  language,  and  translation  from  the  technical  Greek  to  the 
English  vernacular.  We  have  seen  how  in  the  time  of  Aretaeus 
and  Galen  they  were  disputing  as  to  the  etymology  and  significance 
of  the  words  kynanche  and  synanche  (vid.  pp.  07  and  86).  How 
this  word  was  translated  into  the  Syriac  and  Arabic  dialects  I  am 
not  sufficiently  versed  in  Oriental  linguistics  to  know,  but  when  it 
emerged  into  medieval  Latin  it  was  "squinantia,"  a  term  unknown 
to  classical  Latin.  In  the  English  of  Iluxham,'-  not  a  bad  example 
of  a  classical  p]nglisli  medical  writer  of  the  eighteenth  century, 

^  Jo.  Platearii.  .  .  .  Practica  Brevis.  De  Squinantia.  In  Practica  Jo. 
Serapionis  Dicta  Breviarium.     \'cnctiis,  1497,  f.  176,  b. 

-  An  Essay  on  Fevers,  to  which  is  now  added  a  Dissertation  on  Malignant 
Ulcerous  Sore  Throat.    London,  177.5. 


no  THE  P RE-RENAISSANCE  PERIOD 

we  find  the  term  changed  into  "squinzy,"  and  from  this  to  the 
famihar  (jiiinsy  is  but  a  step. 

Giirlt  (Gcschic'hte  der  Chirurgie)  quotes  from  Brunus  de  Longo- 
bardus,  who  ended  his  work  in  1252,  a  passage  by  which  we  may 
see  the  inane  confusion  into  which  this  old  dispute  of  the  Greeks 
had  thrown  their  witless  heirs: 

"  Xam  hujus  apostematis  tres  sunt  species,  quarum  una  dicitur 
quinantia — aha  dicitur  sinantia — aha  dicitur  squinantia."  He 
tries  to  define  the  difference  between  these,  but  he  leaves  the 
modern  reader  in  a  fog,  and  there  can  be  no  better  iUustration 
found  of  the  paucity  of  original  thought  and  observation,  and  even 
of  feebleness  of  imitation  which  is  so  characteristic  of  pre-Renais- 
sance  medicine.  In  the  Glossulse  Quatuor  ^Nlagistrorum  the  same 
differentiation  is  adopted  by  Rolando. 

A  still  further  example  of  obfuscation  and  pedantry  may  be 
obtained  from  the  same  source.  Lanfranc  was  a  surgeon  who  died 
in  1306,  and  this  is  his  idea  of  the  topography  of  the  neck;  it  is 
untranslatable: 

"Quidam  tamen  faciunt  differentiam  inter  collum  et  cervicem; 
gulam  et  guttur;  quae  tamen  omnia  sub  colli  nomine  comprehen- 
duntur  multotiens.  Intra  collum  et  gulam  ab  intra  locatur  meri 
sive  ysophagus — ex  parte  vero  interiori  versus  gulam  locatur 
eanna  pulmonis — super  has  duas  vias  et  epiglotus  ex  tribus  cartila- 
ginibus  compositus.  (The  epiglottis  was  the  usual  mediaeval 
name  for  the  larynx,  'canna  pulmonis'  for  the  trachea.)  Guttur 
dicitur  eminentia  epigloti;  latus  gutturis  dicitur  gula."  Arnoldo 
di  Villanova^  (1285)  speaks  of  "squinantia"  as  a  throat  inflamma- 
tion "inquodam  folliculo  quod  est  inter  ysophagum  et  tracheam." 
Going  back  to  the  first  of  these  writers,  who  drew  their  knowledge 
principally  from  Arabian  sources,  we  look  in  vain  through  the 
ponderous  tome  of  Constantine  the  African  (1015-1087)-  for  any- 
thing \'arying  from  Hippocrates,  Galen,  and  Avicenna  except  in 
the  obscurity  of  diction  and  the  misapprehension  of  its  sense.  It 
is  largely  a  catalogue  of  drugs,  including,  for  the  throat,  the  swallow 
prescription  and  the  usual  line  of  stercoraceous  remedies.  The 
same  may  be  said  of  Gariopontus  (1040) .  They  were  Salcrnitans  and 
the  school  had  then  been  in  existence,  for  a  time  under  the  Saracens, 
for  several  centuries.  It  only  formally  went  out  of  existence  with 
many  other  old  things  in  the  time  of  the  great  Napoleon,  but  it 
had  l)egun  to  decline  even  in  the  time  of  Roger  of  Rarma  (12.")0), 
and  his  disciple  Rolando,  who  were  the  first  writers  in  whom  there 
is  any  evidence  of  originality,  and  this  is  seldom  apparent. 

Operation  for  Nasal  Polypi. — From  the  text  of  Rolando^  we  learn 
that  for  nasal  polypi  he  at  first  purged  the  patient  and  then  "Cum 

1  Opera,  Edit.,  Lugduni,  1509,  f.  166. 

^  De  Morborum  Cofiiiitione  et  Curationo.     In  his:  Opera  Basileac,  153(). 

^  Glossulaj  Quatuor  Alagistroruin.    Edit.  Daremberg,  Neapoli,  1854,  p.  129. 


TONSILLOTOMY,   UVULOTOMY,   TRACHEOTOMY  111 

spatiimine  usque  ad  profundum  evellatur  et  sagitella  inscidatiir." 
The  sharp  spatula  referred  to  is  evidently  from  Galen.  The  recom- 
mendation for  the  use  of  a  saw  may  have  resulted  from  the  descrip- 
tion of  the  use  of  the  knotted  string  in  the  manner  of  a  saw  as 
described  by  Paulus  Aegineta,  just  as  the  latter  probably  through 
imperfect  manuscripts  derived  the  string  operation  from  the  more 
rational  and  humane  sponge  method  of  Hippocrates.  At  least  in 
some  of  the  translations  from  the  x\.rabian  books  reference  to  this 
"sagitella,"  usually  in  the  way  of  comparative  illustration  of  the 
knotted  string  method,  may  be  found;  but  SprengeP  says  that 
Rhases  recommends  the  saw  as  well  as  the  ligature  for  the  removal 
of  nasal  polypi.  Rolando  seems  familiar  with  the  knotted-string 
method  also,  but  nevertheless  I  imagine  there  is  confusion  here 
arising  from  the  transcription. 

Tonsillotomy,  Uvulotomy,  Tracheotomy. — Holmes  refers  to  Roger 
and  Rolando  as  having  observed  a  neoplasm  of  the  larynx.  This, 
when  we  consider  the  general  state  of  medical  diagnosis  in  their 
day,  seems  very  improbable.  The  passage  in  the  "Glossulffi"  to 
which  he  apparently  refers  does  not  seem  to  warrant  that  interpre- 
tation,^ but  it  seems  clear  to  me  that  enlarged  tonsils  was  the  con- 
dition the  writer  had  in  mind.  The  last  sentence  doubtless  refers 
to  tonsillotomy.  Immediately  thereafter  follows  the  reference 
to  the  treatment  of  elongated  uvula.  For  this  he  had  a  good  deal 
of  faith  in  an  ointment,  doubtless  carried  in  the  boxes  of  the  peri- 
patetic practitioners  of  the  day,  the  quacksalbers.  This  salve  was 
supposed  to  destroy  proud  flesh,  and  cause  the  growth  of  better. 
If  no  other  remedv  was  efficacious  the  cauterv  was  to  be  used  as 
recommended  by  the  Arabians  and  "Ypocras."  He  quotes 
Avicenna  in  a  warning  to  be  observed  after  u^■ulotomy,  clearly 
derived  in  exaggerated  form  from  Galen.  The  patient  should  not 
lie  on  his  back,  lest  epilepsy,  apoplexy,  and  paralysis  should  be 
caused.  He  also  had  reason  to  recommend  as  a  gargle  the  water 
in  which  a  fat  hen  had  been  boiled,  a  prescription  which  may  be 
found  in  the  Arabian  works.  Petrus  d'Abano'  warns  against 
incision  of  the  trachea  as  dangerous  and  gives  his  puerile  reasons 
for  the  opinion.  Arnaldo  di  Villanova  (1.  c.)  repeats  the  Arabian 
hair-pulling  formula  for  relaxed  palate,  and  the  fat-hen  prescription 
for  sore  throat.  As  for  the  ridiculous  "Lilium  Mediciiiii.'"  of 
Bernard  Gordon,  a  teacher  at  Montpellier  from  1285  to  1307,  the 
title  reflecting  the  stilted  style  of  chivalry  with  which  Cervantes 

lEssai.     .     .     .     sur  la  Medccine.     Paris,  1809-10,  II,  p.  337. 

-  Est  auleni  quaedaiu  passio  quenascitur  in  gula  juxta  epiglotiiiu  quod  dicitur 
foUum  (?)  que  quandoque  est  una  et  quandoque  sunt  due  carunculse  tenues 
et  late  et  modus  folii  que  tracheam  arteriam  et  vocem  impediunt;  cum  vero 
patiens  aperit  os  ad  loquclam,  se  elevant  et  foramen  trachee  artei'ie;  cum  vero 
OS  claudit,  subsident,  unde  jjatiens  vix  |)otest  formare  alicjuod  v(u-l)um  intelli- 
gible.   Que  passio  numquani  curatur  nisi  beneficio  cvrurgie. 

»  Concil.  Diff.    Venetiis,  1522.    He  lived  12.50-1320  a.d. 


112  THE  PRE-RENAISSANCE  PERIOD 

later  played  such  havoc,  this  seems  an  utter  annihilation  of  cere- 
bration. Dyspnoea  was  sui)pose(l  to  l)e  (hie  to  "weakness  as  in 
chikhen  on  account  of  the  (k'bihty  of  the  nerves  and  paralysis, 
on  account  of  spasm  and  many  such  things,"  he  recognizes 
uvulotomv  and  hints  at  the  advisabilitv  of  tracheotomv  in  verv 
desperate  cases.  The  intractability  of  chronic  hoarseness  is 
expressed,  however,  in  the  tersest  language,  to  which  modern 
science  could  hardly  add  anything.  "  Haucedo  post  ununi 
annum  non  recepit  curationem.  liaucedo  ex  rheumate  numquam- 
curatur,  nisi  prius  rheuma  curatur."  Platearius  (1.  c.)  gave  expres- 
sion to  the  same  opinion.  All  these  authors  shared  the  credulity 
of  their  age.  In  the  records  of  sorcery,  so  abundant  in  the  ]\Iiddle 
Ages,  the  accounts  of  cries  and  coughs  and  barkings,  especially 
among  the  hysterical  recluses  of  the  convents,  were  the  syni})toms 
of  the  convulsive  spasms  of  the  pharynx  and  larynx  still  occasionally 
seen,  and  perhaps,  as  Dupouy  suggests,^  prodromata  of  the  more 
general  convulsive  seizures.  The  ignorant  credulity  of  the  age 
was  extremely  likely  to  cause  the  burning  of  these  poor  wretches. 

But  greater  men  had  begun  to  appear  and  in  Henri  di  Mondeville 
and  Guy  di  Cauliac,  his  pupil  at  the  University  of  ]\Ionti)ellier, 
we  have  evidence  of  advancing  intelligence  and  knowledge,  which 
manifests  itself  however  chiefly  by  a  better  understanding  and 
rendering  of  Galen  and  the  Arabians.  Their  productions  in  their 
naivete  are  amusing,  in  their  form  approach  somewhat  to  the 
standard  of  good  literature,  and  in  their  substance  are  valuable 
as  giving  an  insight  not  only  into  medical  knowledge  and  ethics, 
but  also  to  a  considerable  extent  into  the  spirit  and  general  con- 
ditions of  the  time.  There  is  also  to  be  noted  some  improvement 
in  the  latinity. 

Henry  of  Amondeville. — Henricus  de  Anionde\  ille,'  as  he  styles 
himself,  declares  in  his  Proemium  that  he  set  out  to  write  his 
Manual  of  Surgery  in  1306.  This  is  just  ten  years  before  ]\Iondino 
di  Luzzi  is  said  to  have  dissected  in  public  the  human  body,  and 
it  will  be  interesting  to  note  the  advances,  small  but  significant, 
in  anatomical  knowledge  which  are  evident  in  the  work  of  Ilermon- 
deville  (for  thus  he  is  also  called  at  times),  over  the  state  of  it 
revealed  in  the  citations  I  have  made.  He  describes  the  olfactory 
lobes,  not  according  to  Theophilus,  whose  description  was  not 
noted  until  recent  historians  have  brought  it  to  light,  but  according 
to  Galen  as  a  i)art  of  the  brain  and  the  true  organ  of  smell:  "Just 
in  front  of  these  is  a  certain  fossa  which  is  between  the  two  eyes 
under  the  upper  extremity  of  the  nose,  where  the  said  fossa  begins." 
(He  is  describing  the  internal  nose.)  "The  reason  for  the  creation 
of  this  fossa  is  twofold:  (1)  That  it  may  receive  the  superfluities  of 
the  brain,  and  that  they  may  be  expelled  through  it.    (2)  That  in 

'  Lo  Moycii  Afro  Mrdical.     Pari.s,  1895. 

-  Die  Chirursic  des  lleinrich  von  Mondeville,  edited  by  Pagel.     Berlin,  1892. 


GUI  DI  CAULIAC  113 

it  the  air,  carrying  a  sort  of  odorous  matter,  may  remain  quiet 
until  it  is  taken  up  by  the  organ  of  smell.  From  the  said  fossa 
spring  two  canals  toward  the  mouth  and  the  palate  through  the 
ethmoid  bone.  The  use  of  the  said  canals  are  threefold :  (1)  That 
when  the  mouth  is  closed  there  may  be  an  inspiration  of  air  to 
the  lungs.  If  this  were  not  so  it  would  always  be  necessary  to 
keep  the  mouth  open.  (2)  By  blowing  forcibly  through  these  the 
said  sieve-like  bone  (the  ethmoid)  may  be  purged  of  its  filthy 
viscosities.     (3)  That  they  may  aid  in  the  enunciation  of  letters." 

The  description  of  the  external  nose  which  follows  is  a  little 
better,  but  while  an  improvement  may  be  noted  over  his  immediate 
predecessors,  it  may  be  easily  seen  how  much  inferior  this  is  to 
the  passage  in  Galen  (vid.  pp.  137  and  142),  from  which  it  has  been 
taken,  especially  in  the  physiological  part  of  it.  The  same  remark 
applies  to  the  anatomy  of  the  throat.  "  From  the  stomach  by  way  of 
the  .  .  .  oesophagus^  there  goes  a  membrane,  which  surrounds 
the  whole  mouth  on  the  inside,  and  the  proof  that  it  comes  from  the 
stomach  is  that  when  a  man  is  touched  under  the  mouth  (in  the 
back  of  the  mouth?)  he  immediately  has  a  tendency  to  vomit. 
Extending  into  the  mouth  is  the  upper  end  of  the  oesophagus  and 
the  air  passage  which  is  called  the  'canna  pulmonis  et  trachea 
arteria,'  whose  opening  into  the  mouth  the  cymbalar  cartilage 
covers  which  is  the  third  part  of  the  organ  which  is  called  the 
epiglottis,  i.  e.,  the  nodule  of  the  throat,  which  cymbalar  cartilage 
rises  up  when  a  man  talks  and  covers  very  loosely  the  food  way,  and 
when  a  man  swallows  food  it  is  depressed  and  then  loosely  covers 
the  tracheal  artery  and  the  food  way  remains  open,  wherefore  unless 
at  the  time  of  swallowing  it  should  co\'er  the  airway  food  would 
enter  it,  as  often  happens  when,  etc." 

We  meet  also  with  the  queer  remark  of  Hermondeville  that  the 
flesh  of  the  tongue  is  white  in  order  that  it  may  change  the  watery 
saliva  into  a  color  similar  to  itself.  He  repeats  the  mistake  of 
Galen  that  the  lower  jaw  is  made  of  two  bones.  Among  his  thera- 
peutics invocations  are  occasionally  recommended.  In  all  the 
writers  before  Vesalius  epiglottis  was  a  term  applied  to  the  whole 
larynx,  and  this  and  other  anatomical  terms,  as  among  the  early 
Greeks,  were  used  in  a  bewildering  way  when  they  tried  to  describe 
the  throat. 

Gui  di  Cauliac. — We  now  turn  to  the  great  surgeon  of  the  pre- 
Renaissance  period,  Gui  di  Cauliac,-  and  so  far  as  the  nose  and 
throat  are  concerned  he  does  not  differ  materially  from  his  preceptor, 
Hermondeville.     He  speaks  of  the  ethmoid  bone  as  belonging  to 

^  A  stomachio  mediante  irieri  vel  via  cibi,  vel  ysophago,  quae  sunt  idem." 
Stomachus  in  cla.ssical  latin  usually  meant  the  (Esophagus,  but  was  frequently 
loosely  applied  to  the  stomach,  while  meri  is  apparently  an  Arabian  word 
adopted  into  tlu;  Mediaeval  latin. 

-  La  Grande  Chirurgie  de  Guy  dc  Cliauliac — Composee  en  I'an,  1303.  Edit. 
of  E.  Nicaise,  Paris,  1890. 

8 


114  THE  P RE-RENAISSANCE  PERIOD 

the  frontal,  which  he  calls  the  coronal.  In  it  are  the  holes  for  the 
eyes  and  "les  colatoires  des  narilles  divisez  par  certaine  addition 
ossue  en  forme  d'une  creste  di  geline  a  la  quelle  est  plante  le  cartilas^e 
qui  despart  les  narilles."  (P.  41.)  Although  Gui  has  something 
to  say  of  wounds  of  the  nose  and  bandaging,  he  passes  over  its 
diseases  very  superficially,  quoting  Avicenna  that  the  obstruction 
of  the  nose  is  "humoral,  or  fleshy,  or  crusty,"  the  symptoms  of 
which  are  the  inclination  to  hawk,  the  impossibility  of  breathing 
with  closed  mouth,  tinnitus  aurium,  nausea;  in  short,  not  a  bad 
summary  of  lesions  and  symptoms,  but  not  very  specific.  Plis 
treatment  was  the  snuffing  up  of  water  impregnated  with  various 
mollifacient  and  astringent  drugs.  He  recommends  for  this  purpose 
also  the  urine  of  camels,  having  copied  this,  of  course,  from  the 
Arabians,  who,  in  their  long  and  terrible  journeys  through  the 
burning  sands  of  the  desert,  not  infrequently  were  compelled  to 
quench  their  thirst  with  it  and  to  perform  their  ablutions  with 
sand.  His  account  of  the  diseases  of  the  mouth  and  pharynx  are 
also  merely  repetitions  of  the  medical  writings  of  the  Greeks  and 
Ara])ians.  He  quotes  from  Mesua  a  description  of  a  cannula  for 
cauterizing  the  uvula,  "  in  the  head  of  which  at  one  side  is  a  fenes- 
trum  in  which  the  uvula  is  engaged;  and  then  through  the  cannula 
is  introduced  a  hot  instrument  like  a  knife,  and  it  is  incised  h\ 
cauterizing."  He  also  follows  the  procedures  the  Arabs  had  adopted 
from  Paulus  Aegineta,  for  the  tonsils  and  for  foreign  bodies,  quoting 
Haly  Abbas,  that  if  it  is  a  leech  in  the  throat,  give  onions  with 
vinegar,  or  pull  it  off  with  the  forceps.  In  quinsy  the  following 
treatment  was  used  after  pus  was  supposed  to  be  present.  Quoting 
from  the  practice  of  his  predecessors,  he  says:  "The  abscess  having 
matured,  they  first  try  to  incise  it  with  a  lancet,  if  it  is  to  be  seen, 
and  the  mouth  is  rinsed  out  with  parsley  or  with  some  other  of 
the  usual  detergents.  If,  however,  it  is  so  far  within  as  not  to  be 
seen,  it  should  be  broken  with  the  finger  nail  or  by  rubbing  with 
something  if  possible."  We  are  reminded  of  the  rough-and-ready 
operation  of  the  old  Salernitan  on  the  dice  player.  He  refers  to  this 
remarkable  procedure  of  Roger,  which  we  have  noted  elsewhere 
for  another  purpose.  "A  half-cooked  piece  of  meat  should  be 
taken  and  tied  to  a  long,  strong  cord,  and  the  patient  should 
be  made  to  swallow  it,  and  while  he  is  swallowing  it,  it  should 
suddenly  be  jerked  out  with  violence  by  the  cord,  and  the  abscess 
thus  ruptured.  The  same  may  be  done  with  a  sponge."  This 
was  the  way  Aetius  and  the  Arabians  removed  foreign  bodies, 
but  certainly  there  is  no  lack  of  originality  in  this  for  a  tonsillar 
abscess.  Through  Avicenna  he  quotes  Hippocrates'  intubation 
process  by  means  of  gold  and  silver  tubes  for  the  relief  of  dyspnoea, 
reproducing  the  Arabian  remarks  ujoon  tracheotomy.  The  same 
may  be  said  in  regard  to  nasal  ])oly})i  and  ozwna.  "Of  the  ulcers 
which  are  in  the  nose,  some  are  without  superffuous  flesh  and  others 


THE  INFLUENCE  OF  MARITIME  COMMERCE  115 

with  it.  .  .  .  One  should  not  despise  these  ulcers  of  the  nose, 
since  as  all  say  they  lead  to  polypus,  and  polypus  of  every  kind 
is  pernicious."  For  them  he  recommends  the  process  of  Albucasis, 
the  knotted  cord,  etc.  "Split  open  the  bone  according  to  the  four 
masters,  and  burn  it." 

Botium  was  the  name  in  the  Middle  Ages  for  goitre,  and  they 
knew  nothing  better,  according  to  Gui,  than  the  use  of  setons  for 
the  surgical  treatment  of  it — quite  a  fall  from  Celsus.^  Goitre 
during  these  times,  as  is  well  known,  w^as  cured  by  the  laying  on  of 
royal  hands,  and  the  patriotic  partisans  of  the  kings  of  England 
and  France  carried  on  an  active  and  spirited  warfare  in  quite 
orthodox  fashion,  as  to  the  claims  of  priorit}^  of  their  respective 
monarchs. 

THE  RENAISSANCE. 

The  Influence  of  Maritime  Commerce. — The  removal  of  the  papal 
court  in  1305  to  Avignon,  where  it  remained  for  se^•enty  years, 
gave  Italy  an  opportunity  to  develop  her  own  wonderful  terrestrial 
and  maritime  resources  and  to  lay  a  solid  foundation  for  the  develop- 
ment of  civilization.  For  without  wealth  there  can  be  no  civiliza- 
tion, and  wealth,  as  Spain  gorged  with  the  gold  of  the  Xew  World 
later  demonstrated,  does  not  consist  of  heaps  of  the  yellow  metal 
drained  by  conquest  or  superstition  from  other  countries.  In 
Italy  the  crusades  and  the  religious  devotion  which  made  them 
possible  had  swelled  the  leaking  coffers  of  the  church  in  vain,  but 
when  the  enterprise  of  commerce  had  made  her  merchants  princes, 
the  arts  and  sciences  again  blossomed  along  the  shores  of  the  ]Medi- 
terranean.  When  we  remember  the  foundations  laid  in  the  lives 
of  Darwin,  Huxley  and  Hooker  in  our  own  day  by  the  knowledge 
acquired  on  voyages  in  her  Majesty's  service,  we  may  understand 
the  influence  such  maritime  development  exercised  on  the  budding 
civilization  in  Italy  in  the  fourteenth  and  fifteenth  centuries.  The 
sails  of  Venice  brought  not  only  w^ealth  l)ut  enlightenment  to  her 
wharves. 

The  Genoese  sailor,  the  son  of  a  wool  comber,  had  learned 
indirectly  from  the  Arabs,  whom  his  sovereigns  were  just  driving 
out  of  Spain,  that  the  world  was  round  and  he  was  fitting  out  his 
three  ships  to  prove  it,  less  than  forty  years  after  the  fall  of  Con- 
stantinople had  extinguished  science  in  the  East.  The  church 
had  denied  it.  In  the  process  of  the  suppression  of  the  Pelagian 
heresy  and  the  establishment  of  the  doctrines  of  St.  Augustine, 
the  book  of  Genesis  had  become  the  reference  hand-book  for  the 
cosmography  as  well  as  the  cosmogony  of  the  church.    Supported 

^  It  was  not  until  1443  that  Thomas  of  Sarrano,  afterwai'd  Pope  Nicholas 
V,  discovered  a  manuscript  of  the  De  Medicina  of  Celsus.  Hippocrates  was 
translated  from  the  original  about  the  same  time. 


IK)  THE  RENAISSANCE 

thereby,  we  find  the  infallible  Roman  pontifl'  fixing  the  age  of  the 
world  at  6000  years,  while  as  he  walked  in  the  gardens  of  the 
Vatican,  his  sandals  were  grinding  shells  which  the  sea  had  left 
there  a  million  years  before.  At  first  the  hierarchy  did  noble  work 
in  fostering  the  feeble  shoots  of  learning  which  began  to  appear, 
but  later  when  the  \-igorous  plant  began  to  overshadow  them  they 
strove  to  destroy  it,  or  rather  to  train  it  to  grow  as  they  wished, 
but  in  vain.    It  had  outgrown  their  powers. 

Petrarch. — Petrarch  (1304-1374)  ridiculed  the  ignorance  of  the 
physicians,  and  Boccaccio  (1313-1375)  exposed  and  laughed  at  the 
\-ices  of  the  clergy  long  before  anyone  understood  or  attempted 
to  invalidate  the  slavish  compliance  with  authority  which  so 
degraded  the  human  mind.  Now,  500  years  after  Petrarch,  we 
are  only  reminded  that  this  mental  slavery  once  existed  by  noting 
some  remnants  of  it  in  the  waste  places  of  modern  civilization, 
and  these  are  the  verv  localities  in  which  modern  scientific  and 
political  achievement  had  their  beginning  in  Europe  under  the 
Arabians  and  the  early  popes. 

The  School  of  Salerno  began  as  early  as  the  time  of  Charlemagne 
and  Haroun  al  Raschid  during  the  Arabian  lienaissance,  and 
became  the  Civitas  Hippocratis  to  which  Richard  of  the  Lion  Heart 
and  other  great  personages  resorted  in  the  search  for  health.  By 
the  end  of  the  Crusades  the  Artisan  Guilds  began  to  be  formed, 
family  names  were  adopted,  commerce  and  industry  sprang  up. 
The  commons  in  the  cities  wrested  their  charters  of  freedom  from 
their  sovereigns  in  the  twelfth  century.  The  great  Gothic  cathe- 
drals arose  at  Paris,  Rheims,  Rhouen,  Strasburg,  Amiens.  Saint 
Louis  (1226-1270)  founded  hospitals  in  Paris,  and  his  confessor 
thought  he  was  doing  more  by  establishing  the  theological  school 
of  the  Sorbonne  which  took  his  name.  The  school  of  Bologna, 
where  ^Nlondino  taught,  was  started  in  1119,  and  before  the  fifteenth 
century  uni\ersities  were  fiourishing  in  nearly  all  the  countries  of 
Europe,  and  all  under  the  jurisdiction  of  the  church. 

Revival  of  the  Study  of  Anatomy. — The  Arabians,  as  we  have 
seen,  shrank  in  holy  horror  from  the  contamination  of  a  dead  human 
body,  and  the  students  of  the  School  of  Salerno,  animated  as  it 
was  l)v  Arab  influence  as  earlv  as  the  eleventh  centur\',  studied 
the  anatomy  of  the  pig.  Catholicism  also  proscribed  the  study  of 
anatomy  by  dissection,  and  at  that  time  the  church  represented 
all  the  public  sentiment  there  was,  but  the  enligiitened  Erederick 
II,  while  successful  in  his  warfare  with  the  pope,  connnanded 
(1224?)  that  a  human  body  should  be  dissected  at  one  of  the 
schools  at  least  once  in  five  years,  but  after  him  the  emperors 
kept  no  abiding  power  in  Italy.  The  church  in  those  stormy 
times  could  not  be  long  kept  from  tem})oral  power. 

Mondino  di  Luzzi. — An  edict  of  Boniface  \  II,  ])ublished  in  1300, 
again  pr()liil)itc(l  dissection  not  only  in  Italy  l)ut  in  all  the  countries 


KEREN  GAR  DEL  CARPI  117 

under  sacerdotal  authority.  Nevertheless  only  a  little  time  after 
this,  in  1308,  the  senate  at  Venice  decreed  a  body  should  be  dissected 
annually,  and  in  1316  ^Mundinus  di  Luzzi,  called  the  restorer  of 
anatomy,  being  the  professor  in  the  University  of  Bologna,  had 
the  audacity  to  dissect  two  cada\'ers  in  public.  Besides  the  impor- 
tance of  this  record  in  the  history  of  medicine  it  is  also  a  suggestive 
indication  of  rising  insubordination  against  papal  authority,  much 
weakened  by  the  dissensions  which,  as  we  ha\'e  noted,  had  removed 
the  court  to  Avignon,  and  had  resulted  several  times  in  the  existence 
of  more  popes  than  one.  It  was  also  the  servile  beginning  of 
freedom  from  the  exclusive  authority  of  the  Ancients.  Mondino 
did  little  more  than  open  the  thoracic  abdominal  and  cerebral 
cavities  and  refuse  to  see  anything  not  described  by  Galen.  He 
says^  the  functions  of  the  tonsils  are  "to  gather  the  humidity 
which  they  generate  for  the  lubrifaction  of  the  trachea,  and  to  fill 
up  the  space  so  as  to  make  it  level  between  the  'gula'  and  the 
epiglottis,  and  to  act  as  a  shield  to  the  apoplectic  veins"  (the 
carotids).  He  gives  the  name  cooperatorium  (a  cover)  to  the 
epiglottis,  the  latter  name  as  usual  being  applied  to  the  larynx, 
which  is  described  entirelv  in  the  sense  of  Galen  and  with  the  same 
superficiality  and  lack  of  original  observation  we  have  already 
noted  in  other  writers  of  this  period.  For  nearly  two  hundred 
years  apparently  little  advance  was  made  in  spite  of  the  greater 
prevalence  of  the  practice  of  dissection.  Let  us  not  be  astonished 
at  this,  but  reflect  on  the  few  men  to-day  who  see  at  the  autopsy 
table  or  under  the  microscope  anything  not  set  down  in   books. 

Achillini  indeed  made  some  important  discoveries  (1463-1512) 
in  other  regions  of  the  body,  but  the  editions  of  his  work  are  so 
rare  and  so  wretchedly  executed,  I  have  had  to  depend  upon  the 
citations  of  subsequent  authors.  It  was  not  until  the  study  of 
anatomy  became  a  passion  with  the  princes  of  Italy,  as  it  had 
previously  been  with  the  Ptolemies  in  Egypt,  that  the  great  strides 
noted  in  Berengar  began.  Under  their  protection  the  arts  and 
sciences  flourished,  and  the  study  of  the  anatomy  of  the  human 
body  by  dissection  wrought  great  changes  in  the  practice  of  the 
Medicai  Art. 

Berengar  del  Carpi. — Mondino  is  called  the  Restorer  of  Anatomy, 
but  it  is  to  Berengar  del  Garpi,  who  taught  surgery  at  Bologna 
from  1502-1527,  that  we  owe  the  actual  demoustratiou  of  any 
consideral)le  number  of  new  discoveries.  Although  he  avowed 
himself  to  be  only  the  commentator  of  Moudino,  he  used  the  work 
of  the  latter  principally  as  a  text  from  whic-h  to  elaborate  his  own 
more  extensive  and  accurate  observations. 

In  Benvenuto  Gellini's  entertaining  aut()biogra])hy  we  read  his 
very  uncom])limeiitary  reference  to  Berengar  as  a  charlatan  and  a 

'  Anatomia — Restituta  per  Joh.  Dryandrum.    Marburg,  1541. 


116  THE  RENAISSANCE 

mounteback,  an  impostor  and  a  miser  who  made  enormous  sums 
of  money  out  of  his  new  mercurial  cure  for  cases  of  the  French 
disease,  which  acconhn^  to  CelHni  at  Rome  was  "molto  amici  di 
preti."  AVe  receive  a  hint  of  his  ex])erience  with  sypliihtic  cases 
by  the  error  he  was  led  into  through  his  defective  acquaintance 
with  its  laryngeal  manifestations.  He  notes^  the  declaration  of 
Zerhi  that  certain  French  singers  have  their  uvulae  cut  off  that 
they  may  acquire  a  "grossam  vocem,"  but  he  does  not  believe  it, 
because  he  has  seen  those  having  no  uvula  who  were  hoarse  and 
had  the  worst  kind  of  a  voice.  Following  Galen  he  had  great  res])e('t 
for  the  physiological  importance  of  the  uvula.  Notwithstanding 
that  we  ha^'e  cause  to  remember,  in  reading  the  works  of  Carpi, 
the  declaration  of  Aristotle  that  authority  in  science  is  the  worst 
enemy  of  the  advance  of  knowledge,  and  notwithstanding  the  bad 
stories  related  by  the  uncharitable  Cellini,  Berengar  in  his  Commen- 
taries and  especially  in  his  Isagogae  showed  that  he  was  an  acute 
observer  of  anatomical  facts.  He  thought  when  he  noted  the 
nasal  muscles  he  had  made  a  new  discovery,  but  he  was  not  bold 
enough  to  be  sure  of  it  in  the  absence,  as  he  thought,  of  any  knowl- 
edge of  them  by  others. 

Cartilages  of  the  Larynx. — He  declared,  at  first  with  some  hesita- 
tion in  the  Commentaries  (1521)  and  later  more  positively  in  the 
Isagogse  (1535)  that  the  larynx  is  made  up  of  five  cartilages,  the 
arytenoids  or  "cymbalar  cartilage"  being  double,  but  like  his 
predecessors  he  speaks  of  the  larynx  as  the  epiglottis,  and  uses 
the  word  cooperatorium  as  did  ^Nlondino.  He  says  that  he  had 
cured  patients  with  perforation  of  the  trachea,  but  clings  to  the 
old  belief  that  cartilage  will  not  heal,  "because,"  he  says," it  is 
spermatic."  He  speaks  of  the  substance  of  the  "membranoso 
coopertorio"  the  epiglottis);  "around  this  there  is  some  fat, 
especially  in  the  place  where  it  is  bound  to  the  thyroid  cartilage." 
Most  writers  referring  to  this  passage  agree  with  jNIorgagni  in 
believing  that  Berengar  observed  the  laryngeal  glands  abundant 
at  this  point,  but  after  reading  the  text  it  seems  to  me  more  probable 
that  he  referred  to  the  lymphoid  material  in  the  glosso-epiglottic 
fossa  which  we  now  call  the  lingual  tonsil.  He  was  the  first  to 
describe  the  thyro-epiglottic  muscle.  He  was  the  first  to  describe 
the  sphenoidal  sinus,  which  he  considered  the  source  of  catarrh, 
and  he  denied  that  the  ethmoid  plate  Avas  pervious  to  the  passage 
of  the  cerebral  fluids. 

Sphenoidal  Sinus. — He  supposed  this  to  take  place  through  the 
sphenoidal  sinus,  because  he  noticed  that  in  one  case  the  nutrient 
canal  of  the  bone  communicated  with  the  sella  turcica  beneath  the 
pituitary  body,  which  was  supposed  to  secrete  the  cerebral  fluid. 
So  far  as  I  see  this  was  the  first  departure  from  the  idea  of  the 

^  Carpi  Comment ai'ii.    Anat.  Mmidini,  1521. 


VES ALIUS  119 

ancients,  and  was  an  attempt  to  adjust  physiological  theories  to 
new  anatomical  facts,  which  finally  after  more  than  a  hundred 
vears  ended  in  the  demonstrations  of  Schneider.  He  not  only 
noticed  the  sphenoidal  sinus  and  conjectured  that  this  was  the 
route  of  catarrhal  discharges,  but  he  is  said  by  Cloquet  to  have 
been  the  first  to  note  the  existence  of  the  frontal  sinuses.  Berengar 
speaks  of  the  lacrimal  canal  and  of  the  passage  of  tears  through 
it,  explaining  that  this  is  the  reason  we  are  able  to  smell  odoriferous 
collyria.  Otherwise  his  anatomy  of  the  internal  nose  is  very  super- 
ficial indeed. 

The  Revolt  from  Galen. — Some  of  the  pre-Vesalian  writers  on 
anatomy  stroNe  to  explain  the  countless  variations  they  observed 
from  the  anatomy  of  Galen  by  supposing  that  men  in  those  glorious 
days  were  not  made  in  the  same  mould  as  at  present.  They  had 
degenerated  and  altered  in  their  structure.  This  has  always  been 
a  favorite  idea  with  the  poets  from  Ovid  down.  It  is  embodied 
in  the  very  word  (h'scenchnits,  frequently  lingers  in  the  fond  recollec- 
tions of  age,  and  even  haunts  the  title  of  Darwin's  famous  book, 
who  indeed  has  demonstrated  the  mutability  of  anatomical  struc- 
ture, but  not  in  a  manner  to  support  the  assumption  of  the  anat- 
omists of  the  early  Renaissance,  who  made  timid  excuses  for  the 
originality  of  their  own  observations.  One  may  easily  see  by  this 
ser^•ile  acquiescence  in  authority  that  it  was  not  only  the  temporal 
and  spiritual  tyranny  of  kings  and  priests  which  ensla\'ed  the 
minds  of  men.  It  was  the  distrust  of  intellectual  infancy,  terror 
stricken  at  the  thought  of  the  loss  of  support,  and  guidance  if  they 
impugned  the  authority  of  their  predecessors.  No  fear  of  papal 
excommunication  and  the  burning  fagots,  no  dread  of  being  impaled 
and  racked  and  hung  and  quartered  was  at  the  bottom  of  this 
faltering.  How  ineffectual  these  instruments  of  orthodoxy  were 
when  used  may  be  comprehended  by  noting  that  this  intellectual 
slavery,  without  the  fear  of  fire  here  and  hereafter,  endured  quite 
as  long  as  did  that  spiritual  and  political  subservience  for  the 
l)erpetuation  of  which  they  were  employed. 

Vesalius. — A  few  years  before  the  death  of  Berengar  (1550)  the 
open  revolt  against  ancient  authority  in  anatomy  was  to  appear. 
Vesalius  was  born  at  Brussels  about  1515,  just  one  year  before 
that  mighty  ruler,  Charles  V,  who  had  inherited  half  of  Europe 
from  his  various  ancestors,  ascended  the  throne  of  Spain  and  four 
years  before  he  was  crowned  Emperor  of  the  Holy  Roman  Empire. 
A  great  man  is  Charles  V  in  political  history,  and  not  less  great 
in  medical  history  is  his  physician,  \'esalius.  He  became  pro- 
fessor of  anatomy  at  Padua,  and  taught  also  at  Bologna  and  Pisa, 
before  the  emperor  called  him  to  his  court.  He  made  many  an 
anatomical  blunder  himself,  but  it  is  to  Vesalius  that  this  funda- 
mental branch  of  our  art  owes  its  modern  development.  He 
possessed  that  attribute  of  genius,  which  has  been  expressed  by 


120  THE  RENAISSANCE 

Carlyle  as  the  a})ility  to  sec  with  one's  eyes,  and  the  inal)ility  not 
to  beHeve  what  one  sees.  lie  declared  tliat  Galen  had  never  dis- 
sected the  linman  body,  but  had  depended  upon  examinino;  those 
of  animals,  lie  ridiculed  the  excuses  which  had  begun  to  be  made 
for  the  discrepancies  in  Galen's  anatomy  when  compared  with  the 
results  of  dissection.  He  was  much  readier  to  believe  in  the  falli- 
bility of  the  ancients  than  that  the  structure  of  man  had  varied 
in  a  thousand  years.  It  is  very  e\'ident  that  as  to  the  anatomy  of 
the  nose  and  throat  Vesalius  committed  more  errors  than  he  cor- 
rected, but  his  persistent  refusal  to  accept  either  Galen  or  his 
preceptors'  word  for  that  which  his  eyes  tautjht  him  was  false,  his 
uuAvearied  diligence,  and  boundless  energy  ^^■rought  great  changes 
in  anatomical  research.  He  published  his  great  work  which  would 
have  been  a  worthy  monument  for  the  labors  of  a  lifetime  in  1.142, 
at  the  age  of  twenty-seven.  He  insisted  upon  the  greater  value 
to  be  derived  from  personal  dissection  of  the  human  body,  a  matter 
left  to  barbers  and  underlings  by  his  predecessors  and  by  many 
of  his  contemporaries,  than  by  the  continued  perusal  of  the  ana- 
tomical descriptions  of  the  old  Greeks  and  Arabians,  and  we  find 
him  declaring  in  liitter  scorn  of  one  of  his  preceptors,  who  had 
turned  against  him,  that  he  would  be  quite  content  that  as  many 
strokes  of  the  knife  should  be  inflicted  on  him  as  he  had  ever  seen 
his  master  practise  on  man  or  beast.     (De  Radic.  Chyn.  Epistola.) 

For  him,  as  for  his  predecessors,  and  for  his  successors  for  more 
than  a  hundred  years,  the  secretions  of  the  brain  percolated  through 
the  base  of  the  skull,  but  he  denied  that  it  found  passage  through 
the  cribriform  plate,  following  Berengar  thus  far;  but  he  supposed 
that  it  went  through  the  lacerated  foramina.  Nevertheless  he 
ascribed  to  the  perforations  in  the  cribriform  plate  the  function  of 
transmitting  air  and  odors  to  the  brain,'  urging  the  necessity'  of 
coml)ating  the  idea  of  Galen  as  to  the  exit  of  fluids  through  them. 
His  old  teacher,  Sylvius,  whom  he  tried  to  treat  with  deference 
and  respect,  loaded  him  with  opprobrious  ejiithets  and  scurrilous 
abuse  for  impugning  the  authority  of  Galen  in  this  and  other  par- 
ticulars. 

The  Olfactory  Nerves. — While  \'esalius  recognized  the  mammillary 
processes  as  the  seat  of  olfaction  he  did  not  ascribe  to  them  the 
functions  of  nerves,  overlooking  the  filaments  which  pass  from  them 
and  calling  the  optic  nerves  the  first  pair  at  the  base  of  the  skull 
(1.  c.  Lib.  IV,  cap.  3).  We  have  seen  that  Theophilus  had  given  a 
better  account  of  them  many  centuries  before,  but  his  observation 
seems  to  have  been  entirely  lost  to  view  until  revealed  by  the 
industry  of  comparatively  recent  historians.  We  may  readily 
understand   that   the    mind    of   man   must   necessarily   find    some 

*  De  Humani  Corp.  Fabrica,  Veneti,  1.542,  Lib.  I,  cap.  6  and  12. 

2  Ad    Joachinnim    Roclarils    Epistola.     In     Vesalius,    Ojx'ra   Omnia,    Lu^'d. 
Batav.,  1725,  11,  p.  ()21-()81. 


THE  OLFACTORY  NERVES  121 

explanation  for  the  cribrous  condition  of  the  bone  here,  and  it 
was  quite  impossible  to  banish  erroneous  speculations  until  a 
correct  understanding  was  ready  to  take  their  place.  Zerbi,  who 
lived  at  the  end  of  the  fifteenth  century,  and  met  a  horrible  death 
at  the  hands  of  the  vengeful  and  suspicious  Turks  now  in  possession 
of  Constantinople,^  described  the  filaments  which  the  olfactory 
bulbs  give  off,  but  he  regarded  them  as  prolongations  of  the  mam- 
millary  processes  through  which  the  cerebral  secretions  find  their 
way  into  the  nose.  Most  of  the  anatomists  of  the  sixteenth  century 
regarded  them  as  too  soft  to  be  really  nerves,  but  Achillini,  who 
died  in  1512,  described  their  distribution  in  the  nose.-  ]\lassa, 
who  is  said  to  have  died  in  the  same  year  as  Vesalius  (1504),  wrote-'' 
this  in  regard  to  them: 

"Notwithstanding  the  learned  and  never-to-be-sufficiently- 
praised  Galen,  on  an  examination  of  the  nerves  springing  from  the 
brain,  first  at  the  anterior  part  where  the  substance  of  the  brain  is, 
which  is  called  the  mammillary  caruncles,  there  are  to  be  observed 
two  soft  substances,  yet  they  are  not  so  soft  as  is  imagined,  like 
to  the  form  of  other  nerves,  and  they  descend,  without  any  doubt, 
to  the  nares,  and  are  attached  and  distributed  to  the  inner  substance 
of  the  nostrils,  for  furnishing  the  sense  of  olfaction."  Nevertheless 
he  hesitates  very  much  to  give  them  the  name  of  nerves,  but  is 
inclined  to  believe  they  shoidd  be  so  regarded  in  spite  of  their  soft 
consistence,  and  he  wonders  that  the  anatomists  do  not  name  them 
as  the  first  pair.  Thirty  years  subsecjuent  to  this  Varolus,^  in 
1572,  described  them  as  nerves,  and  in  1627  Spigelius  added  them 
definitely  to  the  other  cranial  nerves.  "Septem  his  paribus  quae 
vulgo  sic  recenscentur  octavum  addimus,  quod  ner\'os  olfactorios 
constitit,"-^  but  even  he  did  not  follow  the  filaments  through  the 
cribriform  plate.  Indeed,  even  Schneider  made  the  egregious 
blunder  of  not  accepting  them  as  nerves.  Bauhinus,'^  in  his  com- 
mentaries on  previous  anatomical  works,  in  1()21,  still  followed 
Plato  in  the  idea  that  odor  is  a  vapor  of  the  nature  of  fire,  which 

1  He  had  been  sent  for  from  Italy  to  treat  a  Turkisli  Bashaw,  who  imi)roved 
so  much  under  treatment  that  the  busy  practitioner  did  not  think  it  necessary 
to  remain  lonjjer,  but  sailed  away  loaded  with  the  gifts  of  the  fjrateful  j^atient. 
No  sooner  had  he  gone  than  the  patient  had  a  relapse  and  died.  His  relatives, 
believing  Zerbi  had  poisoned  him  (or  did  they  want  his  fees?),  overtook  the 
ship  in  which  he  had  sailed  away,  brought  him  back  to  Constantinople,  sawed 
his  son  in  quarters  before  his  eyes  and  then  did  likewise  with  him.  This  storj' 
explains  in  itstdf  why  the  Turks  had  to  send  away  for  a  doctor,  as  did  the  old 
Persians  in  earlier  t  imes. 

-  1  have  derived  from  Sprengel,  Metzger  (Nervorum  Primi  Paris  Ilistoria), 
Clotiuet  and  others  this  account  of  the  work  of  Zerbi  and  Achillini,  as  the 
originals  are,  for  me,  illegible. 

^Epist.  Med.  et  Philosoph.,  Venetiis,  l.'viO,  Epist.  VI,  p.  58. 

*  Cioquct  (Osphresiologie,  ]*]d.  2,  Paris,  1821)  gives  a  most  exhaustive  history 
of  these  nerves,  as  indeed  do(>s  Metzger  (1.  c). 

5  De  Coi'i).  llumani  I'abrica,  Lib.  VH,  cap.  2  (Opera,  Amst.,  1645,  I,  p.  193). 

^  Theatrum  Anatomicum,  I'Yancofurti,  1605,  Lib.  Ill,  cap.  7,  p.  543. 


122  THE  RENAISSANCE 

ascends  throuo;h  the  cribriform  plate.  Fallopius  accepted  the  old 
doctrine  of  Hippocrates  that  vapors  ascend  throii<rh  the  sutures 
of  the  skull.  These  vapors  (ialen,  as  interpreted  ])y  Jacob  Sylvius, 
believed  to  be  separated  from  the  coarser  impurities  in  the  lungs 
which  were  voided  as  plilegm,  the  vaporous  portions  ascending  to 
the  head.  Thomas  Bartholinus/  as  late  as  the  time  of  Schneider, 
although  he  places  the  olfactories  in  the  category  of  nerves,  does 
not  recognize  the  filaments  as  penetrating  the  nasal  cavity.  He 
speaks  of  the  sphenoidal  antrum  and  of  the  hole  in  tiie  sella  turcica 
as  evidence  of  the  entrance  of  air  and  the  discharge  of  the  pituitary 
secretions  from  the  ventricles  through  them,  but  he  also  allowed 
that  secretions  passed  through  the  cribriform  plate,  and  had  the 
Hi])pocratic  idea  of  vapors. 

We  must  now  return  to  the  epoch  of  Vesalius.  He  led  the  revolt 
against  Galen,  but  he  had  many  followers  in  it.  In  a  matter  which 
much  later  was  the  source  of  a  very  important  controversy  he 
agreed  with  Galen. 

The  Intermaxillary  Bone. — He  plainly  figures  an  intermaxillary 
bone.'-  In  this  he  was  followed  by  Fallopius  and  Columbus.  In 
his  comments  upon  the  descriptions  of  the  pharynx  we  find  that 
he  Avas  as  much  bewildered  as  we  have  been,  for  he  says,  "  Ingenti 
nominum  pelago  fluctuamus." 

"Glands"  of  the  Throat. — We  are,  however,  still  somewhat  at  sea 
when  we  read  his  chapter  "De  Faucium  Glandulis,"  though  we 
find  some  advance  over  the  Galenic  anatomy.  I  will  translate 
literally:  "There  are  three  kinds  of  these  glandules,  one  of  which, 
near  the  root  of  the  larynx,  is  situated  at  the  sides  of  the  aspera 
arteria  (thyroid?)  we  have  mentioned  in  the  previous  chapter. 
The  second  is  placed  higher  than  the  larynx,  since  it  is  seen  when 
we  open  our  mouths  in  the  space  which  exists  between  the  fora- 
mina of  the  nostrils  and  the  larynx,  one  glandule  being  placed  at 
each  side,  form  and  characteristics  very  similar  to  a  gland  indeed. 
It  corresponds  very  much  in  structure  to  other  glands,  but  is  much 
looser,  and  in  this  respect  distinguished  that  it  forms  the  saliva 
and  moistens  the  aspera  arteria  and  the  tt'so])hagus  together  with 
the  whole  extent  of  the  mouth."  It  seems  i)robal)le,  from  what 
follows,  that  he  had  observed  the  parotid  gland,  but  had  supposed 
it  to  be  coterminous  and  identical  with  the  faucial  tonsil.  His 
third  kind  of  glands  was  apparenth'  the  cervical  lymph  nodes. 

His  reference  to  the  cartilages  of  the  larynx  is  rather  amusing 
as  indicative  of  his  weariness  of  the  clamor  of  those  who  believed 
anatomy  better  studied  in  the  work  of  Galen  than  in  that  of  the 
Almighty.  We  have  seen  that  Berengar  had  already  pointed  out 
that  there  are  two  arytenoid  cartilages.  Vesalius  repeats  the 
assertion  of  Galen  that  the  larynx  is  made  up  of  three  cartilages, 

'  Anatomia,  1666.    De  Ossibus.  Lib.  IV,  Cap.  8,  p.  495. 

2  De  Hiimani  Corporis  Fabrica,  Basel,  1555,  Lib.  I,  cap.  9,  p.  248. 


ANATOMICAL  PLATES  OF  VES ALIUS  123 

but  he  asserts  that  when  you  take  off  the  membranes  of  this  region 
you  will  find  there  are  two  arytenoid  cartilages,  but  for  the  sake 
of  pleasing  those  who  follow  the  old  anatomists  in  enumerating 
the  cartilages  of  the  larynx  as  three  in  number^  without  describing 
them,  he  will  consider  this  as  a  double  cartilage.  He  defines  the 
glottis  as  the  space  between  the  processus  vocales  and  confines 
the  word  epiglottis  to  its  present  signification,  correcting  and 
criticising  the  errors  and  confusion  of  the  pre-Renaissance  and 
mediaeval  doctors  in  this  respect,  though  he  shared  the  error  of 
Galen  as  did  all  those  who  followed  him  until  the  nineteenth  century 
in  supposing  it  is  the  epiglottis  which  prevents  fluids  from  entering 
the  larynx  in  large  amounts.-  It  seems  singular  that  Vesalius 
Avho  dissected  the  human  body  should  have  ascribed  to  it  the 
muscles  elevating  the  epiglottis  in  animals,^  while  Galen,  whom  he 
charges  with  having  only  dissected  animals,  fails  to  mention  these 
muscles  in  man,  in  whom  thev  do  not  exist.  He  thus  added  two 
muscles  to  Galen's  category  of  twelve,  describing  them  as  almost 
round,  having  their  origin  on  the  internal  surface  of  the  hyoid 
bone  and  being  inserted  at  the  foot  of  the  operculum  or  epiglottis. 
In  regard  to  the  uvula  and  soft  palate  he  does  not  differ  materially 
from  Galen.  He  repeated  the  latter's  vivisection  experiments  on 
the  recurrent  laryngeal  nerve. 

Neither  he  nor  Berengar,  nor  indeed  hardly  any  early  anatomist 
of  great  note,  escaped  the  charge  of  human  vivisection.  With 
Vesalius,  perhaps,  this  hackneyed  accusation  gave  rise  to  the 
story  that  in  expiation  of  this  sin  he  made  the  journey  to  the 
Holy  Sepulchre,  dying  from  shipwreck  and  disease  on  the  return 
voyage  in  1564.  The  latter  fact  seems  well  established,  but  whether 
he  had  been  making  an  expiatory  pilgrimage  or  not,  at  least  for 
this  purpose,  seems  very  doubtful.^ 

Anatomical  Plates  of  Vesalius. — As  has  been  said,  the  time  fur- 
nished a  host  of  anatomists.  None,  however,  surpassed  Vesalius, 
despite  his  errors,  and  no  anatomical  work  has  ever  been  published 
before  or  since,  equaling  or  even  approaching  the  artistic  merits 
of  his  magnificent  plates,  which  to  be  appreciated  must  be  seen  in 
their  original  reproductions.  Indeed,  as  Roth  says:  "In  the 
illustrations  lies  the  fiery  stimulation  and  power  of  his  anatomy." 
Of  course  as  to  accuracy  there  may  be  much  to  criticise  at  present, 
but  even  in  this  thev  were  far  in  advance  of  anvthing  hitherto 
seen.  So  striking  are  they,  that  they  were  at  one  time  ascribed 
to  the  pencil  of  the  immortal  Titian,  and  undoubtedly  they  resemble 

*  It  will  be  noted  tliat  Berengar  speaks  of  the  cartilages  of  the  larynx  as  five 
in  number.  He  included  the  epiglottis  as  we  do  and  made  the  arytenoids  two. 
Other  anatomists,  Vesalius  among  them,  speak  of  the  lar\-nx  as  being  made 
up  of  three  or  four  cartilages,  according  as  they  regarded  the  arytenoids  as 
single  or  double.    Aristotle  had  said  the  epiglottis  belongs  to  the  tongue. 

-  L.  c.  Lib.  I  cap.  xxxviii,  p.  184.  ■''  Lib.  II,  cap.  xxi,  p.  304. 

*  Roth,  Andreas  Vesalius  Bruxellensis,  Berlin,  1892. 


12-4  THE  RENAISSANCE 

the  impress  of  his  genius  left  upon  his  mori'  authentic  prochictions. 
The  identity  of  the  artist  has  never  been  estabHshed,  a  fact  in  itself 
suf2;,<iestive  of  the  unrivalled  artistic  devel()])nient  of  the  epoch 
when  Titian  (1477-1570)  in  his  long  life,  or  Michael  Angelo,  who 
died  in  the  same  year  as  Vesalius,  might  have  traced  their  out- 
lines. In  Cirimm's  life  of  ]\Iichael  Angelo  we  find  it  said  that 
Colombo,  who  was  older  than  Vesalius  (1490-1  ooO),  made  his 
friend,  the  great  artist,  whose  passion  was  anatomy,  a  present  of 
the  body  of  a  young  negro  for  dissection.  It  was  (\)lom])o,  who 
according  to  Sprengel  was  the  first  to  give  a  good  description  of 
the  ventricles  of  the  larynx.  He  also  experimented  on  the  action 
of  the  recurrent  nerves. 

The  Pulmonary  Circulation. — Colombo  is  said  to  have  antedated 
^'ervetus^  in  the  discovery  of  the  pulmonary  circulation.  Vesalius 
had  made  the  mistake  in  the  Epitome  of  the  Fabrica  of  describing 
an  internal  constrictor  muscle  of  the  aperture  of  the  nares,  and  in 
this  error  he  was  followed  many  years  later  by  Thomas  Bartholinus. 
Colombo  denied  this  statement  and  showed  that  such  a  muscle 
does  not  exist.  He  in  his  turn  made  a  mistake  in  describing  the 
cartilages  of  the  larynx  as  being  of  the  nature  of  bone,  ha\ing 
apparently  noted  the  ossification  frequently  found  in  old  people. 
This  was  corrected  by  Laurentius  (or  Dulaurens)^  and  Casserius.'^ 
Colombo  speaks  of  the  superior  maxillary  bone  as  the  os  ampullosum 
on  account  of  the  sinus.^ 

Valverda,  a  Spanish  pupil  of  Colombo,  corrected  Vesalius' 
mistake  as  to  the  muscles  of  the  epiglottis,  although  his  work  is 
largely  a  transcription  of  the  great  Fabrica.  Another  Spaniard, 
high  in  favor  which  Phillip  II,  who  obtained  for  him  an  important 
appointment  in  Sicily  (1563),  was  Ingrassias,  who  was  the  first 
to  describe  the  anterior  ethmoidal  cells  and  likened  the  structure 
of  the  bone  to  pumice-stone.     (Cloquet.) 

The  Turbinated  Bones. — Colombo  and  Ingrassias  both  described 
the  inferior  turbinated  bones,  but  Casserius  a  little  later  (1610)" 
described  them  all,  and  gave  them  their  present  name.  There  are, 
he  says,  hidden  in  the  depths  of  the  nostrils  "oblong  little  bones 
which  may  be  called  spongy,  and  seem  like  the  steps  of  a  bladder, 

'  The  first  description  of  the  puhTionary  circulation  was  pubhshed  by  Servotus 
in  his  "Restitution  of  Cluistianity,"  15.53,  and  the  same  theory  was  contained 
in  the  MS.  copy  sent  to  Calvin  at  the  end  of  1545  or  beginning  of  154ti.  The 
reformer  refused  to  return  the  manuscript  and  lay  in  wait  for  seven  j-ears  to 
slay  its  author  (Whittington).  He  burned  him,  but  it  is  only  fair  to  Calvin  to 
say  that  he  made  no  use  of  his  great  discovery. 

^Ilistoria  Anatomica,  loTS  (Trans,  by  Sise,  p.  1179). 

'  De  \'ocis  Audit  usque  Organis,  IGOO. 

^  In  Re  Anatomica.  I  have;  derived  my  extracts  from  this  author,  as  well  as 
those  which  follow  from  Ingi-assias  and  Valverda,  second  hand  from  many 
sources,  the  originals  not  being  at  my  disposal.  Colombo  was  the  friend,  pupil, 
and  successor  of  Vesalius  in  the  chair  of  Anatomy  of  Padua,  though  apparently 
much  older  than  the  latter. 

^  Pentaeslhesion. 


ANATOMY  OF  THE  LARYNX  125 

because  one  is  placed  above  the  other.  'Ciiculla,'  some  call  them 
I  know  not  through  what  comparison,  unless  perchance  they  wish 
to  liken  the  two  superior  to  a  hood  which,  however,  I  would  rather 
compare  to  the  Concha  Veneris.  Hippocrates  not  inaptly  calls 
them  sleeves.  Turbines  I  would  call  them  from  their  form  and 
function.  They  are  bones,  not  cartilages.  Turbinated  bones 
(Turbinata  Ossa)  they  are  rightly  called.  They  are  usually  three 
in  number,  indeed  this  manv  at  least  alwavs." 

In  the  "De  Usu  Partium"^  Galen  asserts  that  the  bone  in  this 
region  would  better  be  called  spongy  than  like  a  sieve  (ethmoid), 
the  term  applied  to  the  whole  bony  structure  of  the  internal  nose 
by  Hippocrates,-  but  as  for  the  turbinated  bones  as  distinct  parts, 
neither  Hippocrates  or  Galen,  so  far  as  I  see,  betray  any  knowledge 
of  them.  The  illustrations  Casserius  gives  of  them  are  very  poor. 
He  alludes  to  the  cavities  of  the  turbinated  bones,  evidently  meaning 
therebv  the  ethmoid  cells.  The  use  of  the  turbinated  bones,  he 
says,  is  to  break  the  force  of  the  entering  air  and  warm  it  and 
cleanse  it,  which  as  to  the  nose,  we  have  found  in  Galen.  Bauhinus 
(1.  c.)  refers  to  these  authors  and  says  that  the  turbinated  bones 
fill  the  cavity  of  the  nose,  and  are  liable  to  be  eroded  in  syphilis, 
and  he  described  the  anatomy  of  this  region  in  animals. 

Anatomy  of  the  Larynx. — A  treatise  by  Fabricius^  in  1600  contains 
very  good  chai)ters  on  the  structure  and  functions  of  the  larynx, 
but  in  this  he  was  later  surpassed  by  his  pupil  Casserius. 

The  work  of  Casserius  on  the  Organs  of  the  Voice  and  Hearing 
is  a  most  exhaustive  and  admirable  disquisition  on  the  anatomy 
and  physiology  of  the  larynx  and  ear,  comparative  anatomy  of 
the  parts  being  there  very  fully  described  and  pictured  in  finely 
executed  plates.  He  gives  an  elaborate  description  of  the  laryngeal 
muscles.^ 

Fallopius  was  a  man  of  fine  character  and  great  originality  of 
research,  to  whom  medicine  owes  much.  He  was  the  first  to 
separate  the  glossopharyngeal  and  describe  it  as  an  independent 
nerve,  it  having  been  previously,  together  with  the  spinal  acces- 
sory, which  Willis  subsequently  described,  considered  as  a  part  of 
the  vagus.^  He  speaks  also  of  the  nasal  recurrent  branch  of  the 
fifth  pair  of  nerves.  He  devotes  more  attention  to  the  description 
of  the  ethmoid  bone  than  does  Vesalius.     Besides  his  numerous 

1  Lib.  VIII,  cap.  7,  Opera,  (Ktihn)  III,  p.  651 

2  De  Locis  in  Homine,  Opera,  II,  p.  101.     Do  Carnibus,  I,  p.  424. 
^  P^abricius  ab  Acquapeiidente.     De  Visione,  \'oce,  Audit u. 

*  Vesalius,  Fallopius,  Colombo,  Casserius  and  the  other  early  anatomists 
had  very  faulty  ideas  as  to  the  actions  of  the  intralarynfioal  muscles.  Owin^ 
to  the  complexity  of  their  mechanism  this  is  not  to  be  wondered  at.  Indeed 
even  j'et  there  is  much  room  for  difference  of  opinion  and  discussion.  1  would 
refer  the  reader  to  Holmes'  History  of  Larj-ngology  and  especially  to  his  treatise 
on  the  Voice  for  a  more  extensive  and  accurate  description  of  this  difhcult 
matter  than  I  am  able  to  give  here. 

^  Ob.servationes  Anatomica;,  1561. 


126      REFORMATION  AND  DIFFUSION  OF  MEDICAL  SCIENCE 

and  valuable  observations  on  the  internal  ear  he  describes  the 
lacrimal  bones  and  the  lacrimal  duct.  Fallopius  correcting 
Vesalins  declared  he  was  able  to  find  the  hyo-cpi<rlottic  muscle 
only  in  the  ox.  He  gives  a  tolerably  accurate  description  of  the 
pharyngeal  and  palatal  muscles.  While  Galen  speaks  of  but  one 
pair  of  muscles  for  the  palate  and  fauces,  Fallopius  differentiates 
them  into  three  pairs  and  Bauhinus  into  four,  ^'esalius  and 
Colombo  had  followed  Galen  in  believing  the  removal  of  the  uvula 
has  an  injurious  effect  on  the  voice,  but  Bauhinus^  reports  a  case 
in  which  it  was  entirely  removed  without  causing  any  inconvenience. 
It  is  to  Bauhinus  (1.  c.)  much  in  the  modern  nomenclature  of 
anatomy  is  due,  especially  as  to  the  muscles.  Galen  had  named 
the  digastric,  but  in  Bauhinus  we  note  the  sternohyoid,  the 
geniohyoid,  the  crico-arytenoideus  posticus,  etc.  He  also  was 
very  copious  in  his  references  to  the  works  of  others.  He  was 
accused  of  a  lack  of  originality,  but  the  care  he  took  to  quote  his 
authorities,  a  thing  seldom  done  before  him  except  in  the  way  of 
criticism,  was  perhaps  partially  the  cause  of  this  singling  him  out 
from  others  less  conscientious.  He  adds  a  comment  to  the  statement 
of  Galen,  in  regard  to  some  of  the  liquids  in  the  act  of  swallow- 
ing passing  into  the  larynx,  which  is  an  indirect  criticism  of  some 
conceptions  which  still  linger  with  us.  "  For  certainly  unless 
something  flows  along  the  walls  of  the  air  tube  in  aft'ections  of  the 
chest,  ecclegmata,  syruj)s  and  tablets  are  prescribed  in  vain." 
Bauhinus'  idea  of  the  tonsils  was  the  same  as  that  of  the  previous 
writers  from  whom  we  have  quoted.  Even  Casserius  in  describing 
the  pyriform  sinuses,^  which  he  calls  cavernulse,  ascribes  to  them 
the  function  of  holding  for  a  while  a  certain  portion  of  the  liquid  on 
swallowing  which  by  gradually  gliding  down  the  walls  of  the  larynx 
keeps  them  moist  and  lubricates  them.  One  must  keep  in  mind  the 
necessity  of  accounting  for  the  normal  moist  condition  of  the  mucosa 
in  the  absence  of  any  knowledge  of  the  functions  of  the  racemose 
glands.  Laurentius  (1.  c.)  indeed  speaks  of  having  occasionally 
noted  glands  in  the  mucosa  of  the  larynx,  but  their  nature  was 
evidently  unknown  to  him  and  his  contemporaries.  I  have  thus 
far  met  with  no  mention  of  similar  structures  in  the  nose. 


THE  REFORMATION  AND  THE  DIFFUSION  OF 
MEDICAL  SCIENCE. 

We  have  seen  the  Roman  Pontiffs  in  conflict  with  the  temporal 
sovereigns  of  Europe.  We  have  noted  the  Renaissance  of  learning 
and  the  great  anatomical  discoveries  which   it  produced.     The 

1  Theatrum  Anatomicum,  1621,  III,  LXXXIII. 

2  For  an  extended  history  of  the  vallcculie  and  sinus  pvriformes,  see  A. 
Rosenberg  Arch.  f.  Laryng.,  Berhn,  1900,  Bd.  10,  hft.  3,  p.  419. 


INDEX  EXPURGATORIUS  '  127 

princes  of  Italy,  and  at  first  the  popes,  fostered  the  advance  of 
original  investigations  in  science,  but  Buckle  perhaps  includes  them 
in  his  remark  concerning  courtiers.  "They  are  a  lazy  and  feeble 
race,  who,  from  the  frivolity  of  their  habits,  are,  under  ordinary 
circumstances,  predisposed  to  superstition  and  prepared  to  believe 
whatever  the  wisdom  of  their  fathers  has  transmitted  to  them." 
Their  transient  enthusiasm  for  anatomy  would  have  led  to  little 
had  it  not  become  a  serious  pursuit  at  the  universities.  The  Italian 
dukes  were  soon  involved  in  the  contests  between  the  popes  and 
the  emperors,  and  in  the  rude  conflicts  of  the  times  many  of  the 
petty  courts  perished,  as  did  that  of  Ferrara  (1598),  the  dukedom 
of  the  Estes,  the  shelter  and  for  years  the  prison  of  Tasso.  Under 
the  roofs  of  these  little  palaces,  the  scenes  of  intrigue,  murder,  and 
tyranny,  even  in  the  shadow  of  the  walls  of  the  Vatican  itself, 
there  frequently  existed  a  contempt  for  the  tenets  of  the  church, 
and  so  long  as  the  innovations  were  confined  entirely  to  the  intellec- 
tual activities  of  the  favored  few,  there  was  no  interference  with 
the  immense  strides  made  by  them  in  the  arts  and  sciences.  Soon, 
however,  it  became  evident  that  this  progress  was  interfering  not 
only  with  the  temporal  power  of  the  church,  but  was  undermining 
that  spiritual  authority  among  the  masses  upon  which  the  former 
rested. 

The  Inquisition. — The  papal  bull  of  Clement  VII  (1542)  named 
six  cardinals  for  the  more  thorough  exercise  of  the  Inquisition  in 
Italy.  Among  them  was  Cardinal  Carafta,  its  most  zealous  advo- 
cate. He  became  Pope  Paul  IV  in  1555.  Having  failed  in  driving 
away  the  Spaniards,  he  began  that  policy  in  the  States  of  the 
Church  which  quickly  drove  the  sciences,  and  eventually  the  arts, 
out  of  Italy.  "He  frequently  allowed  days  to  pass  by  which  had 
been  appointed  for  the  Segnatura  or  the  Consistorium,  but  never 
the  Thursday  on  which  the  Congregation  of  the  Inquisition  was 
assembled  before  him.  .  .  .  He  gave  it  the  gruesome  privilege 
to  employ  torture  also  for  the  detection  of  accomplices.  He  lived 
and  strove  for  his  reforms,  made  laws,  imprisoned,  excommunicated 
and  held  auto-da-fe's."^ 

Index  Expurgatorius. — Paul  IV  originated  the  Index  Expurgatorius 
in  1559.  A  hundred  years  after  the  discovery  of  a  new  world  to 
which  the  persecuted  might  flee,  one  of  his  successors  inaugurated 
his  pontificate  by  the  pursuit  and  arrest  of  Bruno,  "not  only  as  a 
heretic,  but  as  a  heresiarch  who  has  written  some  things  which 
concern  Religion  and  which  are  not  seemly."  Seven  years  later 
(1600)  they  burned  him  as  Calvin  fifty  years  earlier  had  burned 
Servetus,  both  ecclesiastical  adversaries  being  anxious  to  thus 
supply  "that  protection  against  error  which  the  spiritual  classes 
are  always  eager  to  afford."     (Buckle.)    The  protestant  believed 

^  Ranke's  Geschichte  der  Papstc,  Buch  III. 


128     REFORMATION  AND  DIFFUSION  OF  MEDICAL  SCIENCE 

in  his  own  infallil)ility  qnite  as  firmly  as  his  opponent  believed  in 
the  infallibility  of  the  Pope.  When  they  conld  not  catch  a  heretic 
they  went  ont  and  hnrned  a  witch. ^  Al)ont  this  time  (1580) 
^lontaigne  made  the  sententious  remark:  "C'est  mettre  ses  con- 
jectures a  bien  hant  i)rix,  que  d'en  faire  cuire  un  homme  tout  vif." 

Galileo  did  not  think  it  worth  while  to  be  cooked  for  facts  which 
could  take  care  of  themselves  and  could  not  in  any  event  be  long 
suppressed,  but  on  his  bended  knees  they  made  him  (1().'53)  renun- 
ciate  the  truth  as  he  knew  it.  One  soon  grows  weary  of  reatling 
of  such  senseless  brutality,  and  there  is  little  consolation  to  be 
derived  from  the  thought  that  many  were  burned  who  were  quite 
as  ready  to  kindle  fagots  for  others. 

Decline  of  Commerce  and  of  the  Arts  and  Sciences  in  Italy. — It 
was  not  only  the  Church  desperately  struggling  to  retain  its  influence 
o\-er  the  minds  of  men  which  did  much  to  drive  original  investiga- 
tion in  Science  out  of  Italy,  but  it  was  the  ruinous  policy  of  the 
Papal  court  trying  to  fill  its  leaking  treasury  which  mightily  con- 
tri]:)uted  to  the  same  end.  "  It  is  well  known  that  the  art  of  printing 
flourished  at  A'enice  at  the  beginning  of  the  sixteenth  century,  but 
through  the  regulations  of  the  Curia  it  gradually  dwindled  into 
insignificance.  They  never  ceased  in  Rome  to  forbid  the  publica- 
tion of  books."  (Ranke,  1.  c.)  Besides  the  more  or  less  respectable 
motive  of  stamping  out  heresy,  a  more  worldly  and  contemptible 
tendency  was  exhibited,  which  was  not  edifying  to  the  \'enetians. 
Books  forbidden  by  the  Inquisition  to  be  published  at  \  enice 
were  issued  from  the  presses  at  Rome  owned  in  part  by  cardinals 
active  in  issuing  the  Inquisitorial  restrictions.  They  laid  their 
blundering  hands  on  the  delicate  fabric  of  Italian  commerce. 
Restriction  of  trade  and  an  iniquitous,  meddling  tariff  drove  the 
sails  of  Venice  and  Genoa  from  the  Adriatic  and  the  Mediterranean, 
as  it  has  kept  our  own  from  the  Atlantic  and  the  Pacific.  What 
the  interminable  and  devastating  Italian  wars  at  the  beginning  of 
the  sixteenth  century  failed  to  do,  the  blind  interference  of  the 
Church  with  the  channels  of  thought  and  the  channels  of  trade 
finally   accomplished. 

The  Diffusion  of  Knowledge. — The  very  Avars  of  Italy,  with  which 
indeed  the  whole  of  Eur()]>e  was  convulsed  as  an  indirect  result 
of  the  birth  of  new  ideas,  were  themselves  instrumental  in  carrying 
civilization  and  enlightenment  to  the  benighted  shores  of  Britain 
and  the  opulent  cities  of  Flanders.  The  great  Pare  learned  his 
anatomy  at  Paris  from  Sylvius,  the  preceptor  and  later  the  enemy 
of  Vesalius.     Although   for   several   centuries   the   University  of 

1  The  executions  of  witches  during  six  precctling  centuries  were  probably  not 
as  numerous  as  took  place  during  a  single  decade  of  the  fifteenth  or  sixteenth 
centuries.  After  this  the  practice  rapidly  declined,  being  longest  popular  in 
Calvinistic  Scotland,  though  the  last  witch  was  burned  in  Switzerland  in  1782. 
Leckv,  Historj'  of  the  Rise  and  Influence  of  the  Spirit  of  Rationalism  in  Europe, 
Vol.  1. 


THE  DIFFUSION  OF  KNOWLEDGE  129 

Paris  had  flourished  and  anatomy  had  been  taught  there,  it  was 
in  the  army  of  Francis  I  that  Pare  obtained  that  experience  which 
led  to  the  great  services  he  rendered  surgery.  Vesahus,  born  at 
Brussels,  taught  anatomy  in  Italy,  but  following  the  wide  travels 
and  the  extensive  expeditions  of  the  great  Emperor  Charles,  he 
came  into  contact  with  all  the  civilized  centres  of  population  on 
the  continent.  Thus  and  through  the  channels  of  commerce  were 
the  knowledge  and  the  new  thoughts  of  the  Italian  Renaissance 
spread  broadcast  over  the  face  of  Europe.  Thus  was  a  welcome 
prepared  at  Paris,  Oxford,  and  Ley  den  for  the  arts  and  sciences 
soon  to  be  driven  from  Italy  by  dominant  theology  just  as  they 
had  been  more  eftectually  driven  from  Alexandria  and  Constan- 
tinople. Learning,  of  course,  was  never  entirely  banished  from 
Rome.  "Out  of  all  the  academies  which  arose  from  year  to  year 
one  or  two  were  devoted  to  science,  as,  for  instance,  to  botany, 
although  without  any  results  as  to  original  research,  but  all  the 
others,  with  singular  names,  devoted  themselves  to  poetry  and 
oratory."  (Ranke,  1.  c.)  After  1000  the  arts  also  became  mere 
dilettanteism.  The  soul,  the  spirit  had  flown  and  the  ambition 
of  the  ecclesiastics  and  the  nobles,  directed  by  bad  taste,  led  even 
to  the  lamentable  devastation  of  the  few  remnants  which  had 
remained  from  the  glories  of  Ancient  Rome.  One  must  not  forget 
the  services  rendered  the  medical  art  by  Baglivi  and  Sanctorius 
and  the  Italian  school,  but,  in  spite  of  these,  the  leadership  in 
Medicine  passed  awa^'  from  Italv  at  the  close  of  the  sixteenth 
century. 

Leyden  erected,  in  1574,  within  its  walls  a  university  as  a  trophy 
of  victory  over  King  Philip  and  his  mighty  generals  in  the  Nether- 
lands. Amidst  the  barren  hills  of  Germany,  Luther  absorbed 
from  the  instincts  of  his  race  that  stubborn  freedom  of  thought 
and  independence  of  action  which  stemmed  the  tide  of  subservience 
to  some  of  the  doctrines  and  practices  of  the  Church.  Paracelsus, 
a  drunken  mountebank,  but  a  great  iconoclast  and  doubtless  a 
great  thinker,  performed  a  like  service  for  ]Medicine. 

By  the  middle  of  the  seventeenth  century  the  temporal  power 
of  the  Pope  outside  of  the  contracted  states  of  the  Church  sank 
into  insignificance.  The  various  sects  of  theologians  who  had 
fallen  away  from  the  parent  stem  were,  in  the  nature  of  their 
dift'erences,  so  disunited  and  so  hostile  to  the  Roman  Church, 
that  they  were  impotent  to  stem  the  tide  of  knowledge  which  was 
rising.  The  Royal  Society  of  London  (lOOO),  the  Academy  of 
Paris  (1GG5),  and  similar  institutions  in  (Germany  (1677)  were 
founded  and  became  the  centres  of  scientific  tliought  and  learning. 

In  the  part  of  medical  history  which  now  follows  it  will  be  noted 
that  the  chief  names  are  those  of  trans-alpine  origin.  Harvey  and 
Willis  were  the  great  minds  wiiicli  dominated  medical  thought  in 
England  in  the  seventeenth  century,  not  forgetting  the  immense 


130     REFORMATION  AND  DIFFUSION  OF  MEDICAL  SCIENCE 

influence  wielded  by  Sydenham.  IMalpighi,  born  at  Bologna  and 
working  at  Pisa,  upheld  worthily  the  ancient  glory  of  Italian  medi- 
cine. Leeuwenhoek,  Sylvius  de  la  Boe,  ^'an  lUiNsch,  Boerhaave 
contributed  the  share  of  the  newly  emancipated  Netherlands  to 
the  general  fund  of  scientific  knowledge  gathered  in  this  ej)och.  It 
is,  however,  to  Conrad  Victor  Schneider,  the  learned  Wittemberg 
professor,  to  whom  especially  rhinology,  but  other  branches  of 
our  profession  also,  are  indebted  for  rescuing  the  pathology  of 
catarrh  from  the  slough  of  Galen. 

We  must  now  trace  in  short  outlines  the  epoch-making  discoveries 
in  medicine  which  followed  the  acquisition  of  anatomical  knowledge 
in  the  Renaissance,  especially  those  which  directly  afi'ect  our  subject. 

The  Beginnings  of  Physiology. — Berengar  in  his  time  hafl  begun 
the  difl'erentiation  of  the  ^'eins.  A  half  century  later,  looo,  Ave 
have  noted  that  the  unfortunate  Servetus  had  declared  the  existence 
of  the  pulmonary  circulation  of  the  blood.  Before  Harvey  the 
idea  was  that  the  blood  surged  back  and  forth  through  the  vessels, 
according  to  the  irritation  of  the  parts. ^  It  was  believed  that 
inspiration  drives  the  blood  to  the  vessels  and  expiration  brings 
it  back  to  the  heart.  At  first  even  the  discovery  of  the  vahes  of 
the  veins  did  not  put  observers  on  the  right  track,  for  Cannani 
is  said  to  have  discovered  as  early  as  1547  the  valves  in  the  renal 
and  iliac  veins,  and,  even  more  important,  that  in  the  azygos 
vein.  Fabricius  ab  Acquapendente,  who  was  fortunate  in  having 
had  Fallopius  for  his  teacher  and  Harvey  for  his  pupil,  together 
wuth  Sarpi  in  1574  discovered  these  valves  in  nearly  all  the  veins 
of  the  body. 

The  Circulation  of  the  Blood. — IlarATv  carried  this  knowledge 
home  with  him  to  P^ngland,  and  in  101(3,  the  year  of  Shakespeare's 
death,  he  began  to  announce  his  great  discovery  in  his  lectures, 
which,  however,  was  not  published  to  the  world  until  1028.-  In 
this  great  revelation  he  had  not  only  been  preceded,  as  we  have 
seen,  by  Colombo  and  Servetus  as  to  the  pulmonary  circulation, 
but  there  is  no  doubt  that  Cesalpinus,  who  died  in  lOO.'J,  the  great 
botanist  and  the  physician  of  Pope  Clement,  who  burned  Bruno, 
had  some  inkling  of  the  systemic  circulation.^  When  we  come  to 
study  the  history  of  tracheotomy  we  shall  find  Brasavola,  who  died 
in  1555,  declaring,  as  quoted  by  Holmes,  that  "in  angina,  when 
there  is  no  other  possibility  of  admiUing  air  to  the  heart,  we  must 
incise  the  larynx  below  the  abscess."  With  the  other  errors  of 
the  ancients  this  had  existed  in  medicine  since  the  beginning  of 
its  records.  If  we  should  translate  the  word  pneuma  as  oxygen, 
the  conception  of  the  Greeks  would,  perhaps,  not  seem  so  strange 

^  For  an  exhaustive  review  of  the  ideas  of  the  circulation  before  Harvey,  see 
Daremberg,  Hist.  GC-n^ralo  des  Sc.  M6d.,  Paris,  1S7(),  Vol.  2,  p.  582,  ff. 

2  Excrcitatio  Anatoniica  de  Motu  Cordis  ct  Sanguinis. 

'  See  Ccsalpino  in  the  Dictionnaire  Historique  de  la  Medicine,  (Dczeimeris) 
Paris,  1828,  1,  p.  656. 


THE  OLFACTORY  NERVES  AND  THE  THEORY  OF  WILLIS      131 

to  us  in  very  many  of  their  passages.  However  inaccurate  and 
impossible  this  rendering  would  often  be,  it  would  help  us  to  keep 
in  mind  the  kernel  of  truth  Ijuried  deep  in  the  erroneous  ideas  of 
Hippocrates. 

Before  Harvey  had  published  his  great  work,  Faber,^  in  1624, 
had  ascertained  by  investigation  that  not  the  smallest  amount  of 
air  passed  into  the  heart  from  the  lungs.  Harvey  also  pointed 
out  that  the  air  in  the  trachea  does  not  pass  beyond  its  idtimate 
subdivisions.  Thus  was  this  fundamental  fact  in  medicine,  so 
important  especially  to  modern  laryngology,  established,  after 
the  usual  period  of  resistance  and  discussion. 

The  Correction  of  the  Error  as  to  Catarrh. — Now  let  us  immediately 
turn  to  the  further  elaboration  of  the  history  of  the  other  fact  so 
important  to  the  development  of  our  knowledge  of  the  diseases 
of  the  upper  air  tract,  viz.,  the  existence  of  the  mucous  glands  and 
their  functions.  We  have  followed  the  error  of  the  origin  of  catarrhs 
down  to  the  time  of  Schneider.  Just  as  we  have  perceived  the 
necessity  for  some  explanation  of  the  moisture  of  the  surface  of 
the  mucosae,  so  we  may  understand  the  influence  of  the  growing 
improbability  that  fluid  percolated  through  the  bony  foramina 
at  the  base  of  the  skull.  Berengar  we  ha^'e  seen  imagining  a  waj' 
for  the  catarrh  through  the  nutrient  canal  of  the  sella  turcica 
and  the  sphenoidal  sinus.  Vesalius,  in  spite  of  Sylvius,  also  refused 
to  accept  the  cribriform  plate  as  a  true  sieve,  and  found  a  way  for 
the  drain  of  the  supposed  secretions  of  the  brain  through  the 
lacerated  foramina. 

The  Olfactory  Nerves  and  the  Theory  of  Willis. — I  have  cjuoted 
Zerbi's  idea  that  the  processes  given  off  from  the  olfactory  bulbs 
were  wicks  for  the  drip  of  the  cerebral  fluids  into  the  nose.  Any- 
one familiar  with  the  old  process  of  making  dip  candles  w^ill  under- 
stand the  idea.  Perhaps  this  was  the  germ,  transmitted  of  course 
from  Galen,  of  the  idea  of  Willis,^  whose  works  were  contempora- 
neous with  those  of  Schneider. 

Willis  and  his  school  believed  firmly  in  the  existence  of  an  actual 
nervous  fluid,  just  as  we  find  it  convenient  to  assume  the  existence 
of  a  nervous  electric  fluid.  The  nervous  fluid  of  Willis  was  the 
secretion  of  the  brain.  Some  of  this  was  received  through  the 
infundibulum  b}'  the  pituitary  gland,  which  he  seemed  to  regard 
as  a  sort  of  reservoir  for  the  superfluous  fluid  which  was  carried 
away  by  the  bloodvessels.  He  believed  the  nerves  were  porous 
and  carried  this  vital  animal  fluid  from  the  brain  to  difl'erent 
parts  of  the  body,  supplying  them  with  nutriment  and  animal 
force.    He  says  :^  "Within  the  cavities  of  the  nose  there  are  tubular 

iSprengol:  Hist,  de  la  Med.,  Paris,  1815-20,  IV,  p.  174. 

^  Dc  Cerebri  Anatome,  cui  accessit  Nervorum  Dcscriptio  et  Usus,  London, 
1664. 

'  De  Anirna  Brutorum.  De  Sensu  Oifactus,  Cap.  13.  (Opera  Omnia.,  Amst., 
1682,  p.  64.) 


132     REFORMATION  AND  DIFFUSION  OF  MEDICAL  SCIENCE 

membranes  which  contain  thickly  woven  sensile  fibers.  In  tliese 
membranes  there  are  a  ninnber  of  slender  nerves  given  off  from 
the  mammillary  ])rocesses  throu<;h  the  cribriform  plate."  He  insists 
that,  althonijli  the  base  of  the  skulU  seems  closed  })v  membranes 
in  the  dead  animal,  the  serum  is  so  lim])id  and  the  nerves  so  ])orons 
that  "nothino;  is  more  certain  than  that  the  serous  humors  are 
distilled  from  the  nerves  like  serum  from  the  membranes  in  swollen 
joints,"  This  idea  is  again  expressed  in  the  "Nervorum  Descriptio 
et  Usus,"  where  he  derives  the  mammillary  processes  from  the 
cerebral  ventricles  that  they  may  there  receive  the  serosities  and 
transmit  them  through  the  olfactory  bulbs  to  the  nasal  mucosa, 
which,  from  the  supposition  that  it  contained  tubules,  was  thought 
capable  of  transmitting  vapors  and  odors  from  below  to  the  brain. 
The  Vascular  Theory  of  the  Nasal  Glands. — It  is  probable  that 
this  erroneous  idea  and  that  of  \  an  Ruysch,  who  believed  that  the 
bloodvessels  had  tiny  openings  through  which  serum  is  distilled 
but  not  blood,  arose  from  the  observation  of  the  little  beads  of 
clear  secretion  which  may  be  observed  by  the  naked  eye  to  exude 
from  the  mouths  of  what  we  now  know  are  the  racemose  glands. 
We  must  follow  these  erroneous  ideas  far  beyond  the  time  of 
Schneider  and  then  retrace  our  footsteps  in  order  to  follow  the 
right  path  upon  which  the  latter  entered.  \an  Iluysch,  whose 
"Thesaurus  Anatomica"  was  published  nearly  fifty  years  after 
the  works  of  Schneider,  thus-  speaks  of  the  mucosa:  "Nasal  glands 
may  be  plainly  seen  here,  since  they  are  suffused  with  redness,  on 
account  of  the  fulness  of  the  arterioles,  and  these  are  nothing 
except  bundles  of  the  extremities  of  the  arterioles,^  moistening 
the  nose,  which  so-called  glands,  in  the  live  man  as  well  as  in 
the  dead  man,  escape  detection,  but  in  the  specimen  are  plainly 
demonstrated  by  our  method"  (i.  e.,  the  injection  of  wax  into  the 
arteries).  Diemerbroek^  preferred  Willis'  explanation  to  Schnei- 
der's, but  modified  it  somewhat,  believing  the  holes  in  the  cribriform 
plate  were  filled  by  "nervous  tubular  meml)ranes  derived  from  the 
dura  mater,  which  open  into  the  fungoid  flesh  of  the  nostrils,  which 
is  attached  to  the  spongy  bones,  and  through  these  tubules  mucus 
is  transmitted  from  the  ventricles  of  the  brain  to  the  fungous  flesh 
in  which  they  terminate.  This  is  the  reason  that  something  may 
come  from  the  brain  into  the  nose,  but  nothing  can  go  from  the 
nose  into  the  brain,  since  when  anything  ascends  it  is  stopj)ed  by 
the  arrangement  of  the  ends  of  the  tubules  in  the  flesh."  He 
declares  that  these  tubules  may  be  seen  with  the  magnifying  glass 
if  the  upper  bone  of  the  roof  of  the  nose  is  removed.    The  tubules 

'  De  Cerebi-i  Anatome,  Cap.  12,  p.  142. 
2  Thes.  Anatom.,  VI,  3,  Not.  2. 

^  The  idea  of  (he  glands  in  the  mucosa;  being  a  bunch  of  bloodvessels  was 
a  favorite  doctrine  with  Bellini  (16(55)  and  the  Italian  School. 

■•  Anatome  Corporis  liuniani,  Kd.  1G72,  Liber  IX,  Cap.  7  and  Lib.  Ill,  Caj).  8. 


THE  PREDECESSORS  OF  SCHNEIDER  133 

may  then  be  seen  hanging  to  it.  He  denied  the  assertion  that  these 
structures  are  nerves,  and  refused  them  a  place  as  the  first  pair. 
A  cold  for  some  reason  causes  not  only  an  increase  in  the  cerebral 
secretions,  but  the  contraction  of  the  cerebral  membranes  drives 
it  into  the  nerves.  We  find  Caspar  Bartholinus,  the  son  of  Thomas, 
in  1679^  after  referring  to  Schneider,  still  agreeing  with  the  doctrines 
of  ^Yillis.  Although  Dionis-  refused  entire  credence  to  the  idea 
of  Willis  as  to  the  porosity  of  the  nerves,  and  entirely  rejected  the 
permeability  of  the  ethmoidal  foramina,  he  still  ascribed  to  the 
sutures  of  the  skull  the  function  of  permitting  the  transpiration 
of  the  vapors  which  arise  from  the  brain  and  its  membranes.  He 
also  believed  that  they  permitted  absorption  of  external  medication 
through  them  to  the  organs  within  the  skull.  Bryan  Robinson, 
and  especially  Nicholas,  in  his  treatise  on  Hypochondria  (1719), 
finally  entirely  refuted  the  opinions  of  those  who  believed  with 
Willis  that  the  nerves  were  hollow  channels,  and  called  in  doubt  the 
existence  of  the  fluid  which  was  supposed  to  be  carried  through  them.^ 

The  Acini  of  the  Glands. — To  understand  the  persistent  hold 
this  idea,  in  the  face  of  Schneider's  work,  had  on  the  medical  mind, 
we  must  remember  that  Hippocrates  looked  upon  the  brain  as  a 
gland,  and  the  whole  fabric  of  his  system  was  permeated  with  this 
belief.  It  persisted  even  with  Malpighi,  who  did  so  much  with 
the  microscope,  demonstrating  not  only  the  red  globules  of  the 
blood  (IGGl),  the  air  vesicles  of  the  lungs,  and  many  other  phe- 
nomena, but  the  hollow  nature  of  the  acini  of  the  conglomerate 
glands.  Malpighi's  friend,  Carolus  Fracassatus,  writes  to  him  thus 
concerning  the  brain  :^  "  I  think  it  is  a  pneumatic  instrument  which 
is  an  aid  to  movement  and  sense  through  the  nerves — air  ascends 
through  the  nerves  to  the  brain.  In  Malpighi's  response  to  this 
letter  it  is  evident  that  he  knew  nothing  to  the  contrary.  On 
microscopic  examination  of  the  cerebral  ganglia  he  declared  their 
structure  to  be  glandular  in  character.  Glisson,  who  also  did  so 
much  to  advance  the  knowledge  of  the  viscera,  and  many  others, 
had  the  same  idea.  Wharton  refused  to  accept  this  view,  though 
he  believed  the  nerves  acted  as  channels  for  the  transmission  of 
fluids." 

The  Predecessors  of  Schneider. — Notwithstanding  the  prevalence 
of  all  this  error  even  among  the  very  men  who  were  gradually 
working  out  the  truth,  long  before  Schneider,  we  may  recognize 
the  advent  of  the  conceptions  which  he  founded  as  fact  by  actual 
observation.  I  am  indebted  to  Sprengel  (HI,  p.  280)  for  this 
quotation  from  a  work  first  published  in  1540:^  "Moreover 
Cardanus  suggests  that  the  mucus  which  runs  from  the  nose  and 

iThoma;  Bartholini,  Acta  Medica  et  Phil.,  Hafn.,  1G80,  V,  p.  61. 
^  Cours  d'Anatoniie,  1701.  ^  Sprongel,  V,  172. 

^  Malpighi:  Epistola  Anatomica  De  Cerebro.  In  his  Opera  Omnia,  Lugd. 
Batav.,  1()S7,  II,  p.  113. 

^Cardanus:  Contiadic.  Med.  Lib.  II,  tr.  I,  Cap.  4,  p.  443. 


134  SCHNEIDER:  "DE  CATARRHIS" 

mouth  does  not  really  come  from  the  head,  but  very  often  it  is 
produced  by  the  secretory  organs  of  the  nose  and  throat."  ^  an 
Ilelmont/  who  died  in  1644,  twenty  years  before  the  publication 
of  Schneider's  book  on  Catarrh,  had  a  less  accurate  notion  of  the 
origin  of  pharyngeal  secretions  than  Cardanus,  but  he  at  least  did 
not  ascribe  them  to  the  brain.  Following  Paracelsus  in  his  mys- 
ticism somewhat,  but  greatly  surpassing  him  in  honesty  and  actual 
knowledge,  he  did  much  to  introduce  chemical  ])rinciples  into 
medicine.  He  seems  to  have  been  the  first  to  assert  that  diseases 
are  local  in  their  actions  and  not  dependent  on  a  disturbance  of 
the  whole  body  or  any  vital  principle. 

Van  Helmont  says:  "The  mucosities  which  are  expelled  by  the 
expectoration  and  in  coryza,  do  not  come  from  the  head  nor  are 
they  secreted  by  the  arteries,  but  they  arise  from  superfluity  of 
aliments  which  remain  adherent  at  the  upper  part  of  the  pharynx." 

AVepfer,  whose  work  was  first  published  in  1658,-  has  the  following 
reference  to  the  origin  of  catarrhs  and  the  destination  of  the  vapors. 
He  says  that  the  latter  were  supposed  to  extend  from  the  stomach 
to  the  head,  "just  as  though  the  head  was  to  be  compared  to  the 
smoky  roof  of  a  house  or  the  lid  of  an  alembic,"  but  he  denied 
the  possibility  of  this  except  by  means  of  the  carotid  vessels.  "At 
the  base  of  the  brain  are  the  thick  meninges,  at  that  point  most 
impenetrable  and  almost  four  times  the  usual  thickness.  The 
cranium  in  the  live  animal,  or  in  the  animal  just  dead  and  not  yet 
deprived  of  all  the  membranes,  should  not  be  thought  to  be  similar 
to  the  representations  of  it  in  books  on  the  bones.  Especially  all 
those  holes  which  are  seen  at  the  base  are  occluded  so  that  no 
ingress  or  egress  is  allowed  to  the  vapors  or  the  humors,  as  may 
easily  be  determined."  How  much  of  this  may  have  been  derived 
from  Schneider's  work  on  the  ethmoid  bone  pul)lished  shortly 
before,  does  not  appear.  We  see,  therefore,  as  we  have  noted  in 
the  discovery  of  the  circulation  of  the  blood  by  Har^•ey,  that  the 
idea  of  the  local  origin  of  catarrhal  discharges  had  long  existed 
in  the  world  before  Schneider,  and  we  have  seen  that  the  error  of 
their  cercl)ral  origin  persisted  mam'  years  after  his  death  (1680). 

The  "De  Catarrhis"  of  Schneider. — A  view  of  the  voluminous 
writings  of  Conrad  Victor  Schneider  may  well  appall  the  stoutest 
heart.  Never  was  the  kernel  of  an  important  fact  so  wrapped  up 
in  the  husks  of  verbosity.^  The  dissertation  on  the  cribriform 
bone  is  a  treatise  which  opens  the  way,  as  must  have  done  the 

'  Opera  Omnia.     Catarrh.     Delirament,  p.  412.     Ed.  1682. 

^  Observationes  Anatomica?  ex  Cadavcribus  oorum  quos  sustulit  Apoplexia, 
1727,  Obs.  CIV,  p.  459. 

■■'  The  patient  reader  maj^  be  referred  to: 

Dissertatio  de  esse  cribriforme,  1G55. 

De  Catarrhis  Hbri  ¥1-1(360—1661. 

De  Catarrhis  hber  speciallissimus — 1664. 

Although  exceetlingly  verbose,  still  his  Latin  style  is  perspicuous  and  by 
no  means  wearisome  reading. 


THE  EVOLUTION  OF  KNOWLEDGE  OF  MUCOUS  GLANDS      135 

investigations  on  which  it  is  founded  for  the  author's  thoughts,  to 
the  larger  work  on  Catarrh,  for  in  his  opening  remarks  he  insists 
upon  the  impermeabihty  of  the  base  of  the  skull  to  liquids  or  air. 
The  grateful  reader  may  well  excuse  any  omissions  in  the  following 
exceedingly  compressed  account  of  Schneider's  dissertations  on 
Catarrh.  He  showed  that  the  origin  of  the  catarrhal  discharges 
cannot  be  in  the  cranial  cavity,  and  they  could  not  get  out  if  such 
secretions  were  formed  there,  since  neither  the  cribriform  plate 
nor  the  nutrient  canal  of  the  sphenoid  bone  nor  the  lacerated  fora- 
mina, as  claimed  by  various  writers,  are  pervious.  As  a  matter 
of  fact,  no  fluid  so  viscid  as  mucus  is  to  be  found  there  at  all. 
Neither  could  it  be  born  through  the  nerves.     (Libri  I  and  II.) 

He  described  a  new  origin  for  nasal  discharge  in  the  anterior 
and  posterior  pituitary  membranes,  as  he  calls  them.  ]\Iucus 
may  be  squeezed  out  of  the  membranes  of  these  regions  even  in 
the  dead  subject.  He  does  not  once  mention  the  glands  as  the 
source  in  the  mucosa  of  this  mucus.  He  speaks  in  the  same  way 
of  the  tonsils  and  of  the  ocular  and  lachrymal  mucosa.  The  anterior 
and  posterior  pituitary  membrane  when  normal  exudes  this  mucus 
moderately.  ^Yhen  more  is  exuded  catarrh  arises.  He  insisted 
that  in  coryza  the  brain  is  not  affected  at  all.  Even  in  a  horse 
dying  of  glanders,  the  brain  was  found  unaffected.  There  can  be 
no  doubt  from  his  description  of  what  he  calls  the  posterior  pituitary 
membrane  that  he  had  noted  the  existence  of  lymphoid  hypertrophy, 
but  he  does  not  clearly  recognize  it  as  pathological.  (Libri  III 
and  IV.)  His  etiology  of  catarrh  is  hardly  worth  transcribing  and 
the  same  may  be  said  of  the  treatment,  notwithstanding  the  radical 
character  of  the  advance  he  made  in  the  knowledge  of  the  physiology 
and  pathology  of  the  nose.  Coryza  he  defines  as  a  catarrh  of  the 
anterior  pituitar\'  membrane,  while  under  the  head  of  posterior 
pituitary  catarrh  he  includes  affections  of  the  throat.  Branchus 
is  a  name  he  gave  to  too  great  a  secretion  from  the  larynx.  Appar- 
ently he  derived  this  from  Paracelsus.  It  did  not  long  continue 
in  use  after  his  day.  When  the  latter  is  accompanied  by  difficulty 
in  breathing  of  all  kinds  he  called  it  catarrhus  suffocativus,  and 
this  term  persisted  for  more  than  a  hundred  years  in  medical 
literature,  notwithstanding  the  differentiation  which  was  con- 
stantly going  on,  and  for  a  time  was  synonymous  both  with 
diphtheria  and  with  bronchial  asthma. 

The  Evolution  of  Knowledge  of  the  Mucous  Glands. — ^\Vliilc,  there- 
fore, it  was  Schneider  who  clearly  demonstrated  that  the  mucosa 
itself  is  the  source  of  catarrhal  discharges,  he  did  not  demonstrate 
those  structures  in  the  mucosa  in  which  it  is  formed  and  from  which 
it  escapes,  i.  e.,  the  racemose  glands.^      If  the  reader  will  refer 

'  Let  us  for  the  sake  of  simplicity  avoid  the  complicated  question  as  to  how 
much  of  the  nasal  sccrotions  come  directly  from  the  bloodvessels  witliout  passing 
through  glandular  epithelium. 


136  THE   LYMPHATICS 

back  to  the  quotation  of  Marinus  I  have  taken  from  Galen  (p.  82), 
it  Avill  at  once  be  apparent  that  while  what  the  ancients  called 
glands  had  been  noted,  their  function  was  for  the  most  part 
unknown,  and  included  many  thin<i;s  which  are  no  lonrrer  regarded 
as  glands,  the  distinction  between  the  congloljate  and  the  con- 
glomerate, or  the  lymph  nodes  and  the  racemose  glands,  being  of 
course  entirely  unsuspected.  In  the  course  of  this  history  we  have 
found  reference  to  the  brain,  the  tonsils  and  the  thyroid  glands 
as  moistening  the  adjacent  mucosae.  While  the  nature  of  the 
brain  and  that  of  the  tonsils  have  long  been  known,  it  is  only  of 
recent  years  that  the  thyroid  physiology  has  begun  to  be  elucidated, 
though  Haller  a  hundred  and  fifty  years  ago  asserted  in  his  Physi- 
ology that  it  had  to  do  with  the  elaboration  of  the  blood.  Many 
had  speculated  as  to  the  function  of  the  thyroid  gland.  Desnoues, 
who  is  said  to  have  originated  the  method  of  injecting  of  blood- 
vessels with  wax  in  his  demonstrations,  and  Coschowitz,  both  of 
them  seventeenth  century  observers,  declared,  according  to  Haller, 
they  had  found  the  ducts  of  the  thyroid  opening  into  the  foramen 
caecum  of  the  tongue.    This  was  refuted  by  Morgagni. 

I  quote  from  the  "  Adeno-Graphia  Curiosa"  of  Nuck,  pul)lished 
first  in  1692,  "Those  who  first  began  to  examine  the  structure  of 
glands,  both  conglobate  and  conglomerate,  were  Wirsung,  Wharton, 
and  Steno,  who  not  only  demonstrated  the  size  and  shape  of  the 
glands,  but  their  inlets  and  outlets."  It  may  be  noted  that  Nuck, 
though  he  does  not  in  his  catalogue  allude  to  the  nasal  glands, 
speaks  of  those  of  the  membranes  in  general  as  clinging  close  to 
their  substance.  Knowledge  of  the  true  condition  of  affairs  as 
to  the  origin  of  catarrh  had  advanced  so  far  with  many  observers 
as  to  induce  Nuck  to  write  a  humorous  epitaph  upon  the  pineal 
gland  as  such.  The  history  of  the  racemose  glands  of  the  mucosae 
is  so  inextricably  interwoven  with  that  of  the  glandular  organs 
of  the  general  system  that  they  caimot  well  be  separated. 

The  Chyliferous  System. — Eustachius  had  already  in  the  sixteenth 
century  described  the  thoracic  duct.  Aselli,  in  1622,  announced 
the  discovery  of  the  lacteals  in  the  mesentery,  the  existence  of 
which,  illustrating  the  fallibility  of  great  minds,  was  obstinately 
and  persistently  denied  by  Harvey.  In  1641-3  Iloirmann,  Wirsung, 
Riolan  Wormius  discovered  and  confirmed  the  existence  of  the 
pancreas  and  its  connection  with  the  digestive  process.  Pecquet 
a  few  years  later  discovered  the  chyle  in  the  vena  cava  coming 
from  the  thoracic  duct  by  way  of  the  subclavian  vein,  and  again 
the  rule  of  human  fallibility  was  followed  by  Aselli,  who  denied 
the  reality  of  Pecquet's  addition  to  his  own  discovery  (Sprengel 
IV,  209). 

The  Lymphatics. — Gradually  the  lymphatic  system  was  proved 
not  to  be  a  part  of  the  chyliferous.  Fallopius,  many  years  pre- 
viously, having  noted  the  lymphatics  of  the  liver,  Rudbeck  distin- 


THE  MUCOUS  GLANDS  137 

giiished  them  from  the  lacteals  more  recently  discovered  by  AselH. 
The  Uver  became  an  excretory  instead  of  a  secretory  organ  after 
Ghsson  has  ekicidated  its  anatomy.  Thomas  \Yharton/  whose 
name  survives  attached  to  the  duct  of  the  submaxillary  gland, 
asserted  the  brain  is  of  a  different  nature  from  the  glands  and 
other  viscera.  In  spite  of  many  mistakes  he  added  greatly  to  our 
knowledge  of  the  structure  and  functions  of  the  glands. - 

Franciscus  de  la  Boe  Sylvius,^  according  to  Haller,  was  the  first 
to  separate  the  conglomerate  from  the  conglobate  glands,  our  race- 
mose and  lymphatic  glands  respectively.  His  pupils,  Steno  and 
De  Graaf,  greatly  extended  this  differentiation.  De  la  Boe,  follow- 
ing the  thought  of  Galen  in  c^uoting  ^Nlarinus,  says  that  there  are 
two  primary  kinds  of  glands.  "For  there  are  some  as  if  made  up 
of  separate  parts  and  from  smaller  conglomerate  glands,  stuck 
together,  as  it  were,  with  some  inequality  of  the  surface,  such  as 
the  pancreas  and  thymus.  Others  are  observed  to  have  a  smooth 
surface  and  as  if  blown  up  and  moulded  together.  {E.v  una  quasi 
sibi  continuata  substantia,  confiatcB  et  conglobatoe .)  Such  as  are 
contained  in  the  mesentery  and  in  the  groin  and  elsewhere  are 
supplied  with  lymphatic  vessels.  To  this  may  be  added,  if  desirable, 
a  third  kind,  the  renal  glands  and  their  accessories." 

The  Mucous  Glands. — ^Yhile  there  is  much  said  by  this  author 
of  the  pancreatic  and  salivary  glands  as  distinct  from  the  lymphatic 
or  conglobate  glands,  no  mention  is  made  of  the  muciparous  glands. 
To  Steno,"*  perhaps,  more  clearly  than  to  anyone  else,  belongs  the 
credit  of  first  describing  them.  He  described  the  larger  glands  of 
the  mouth  and  eyes  and  the  vessels  of  the  membrane  of  the  nose, 
which,  he  declares,  are  of  two  kinds,  and  they  exist  in  the  mucous 
membrane  for  the  purpose  of  keeping  them  moist.  Steno  first 
noted  the  duct  which  bears  his  name  in  16G0,  but  it  had  been  known 
to  others  before  him.  Sprengel  (IV,  p.  236)  quotes  Walther  for 
authority  in  asserting  that  Rivin  was  the  first  to  discover  the 
duct  of  the  sublingual  gland  which  Caspar  Bartholinus,  the  son 
of  Thomas,  claimed  the  honor  of  first  noting  in  1GS2,  ranula  or 
dilatation  of  this  duct  having  been  known  and  operated  on  from 
the  earliest  times.^     Xuck  (1.  c.)  added  a  greater  exactitude  and 

*  Adenographia  sive  Glandularum  totius  Corporis  Dcscriptio,  1656. 

^  Those  who  desire  to  find  an  account  of  the  services  rendered  to  medicine 
by  Wharton,  as  well  as  an  account  of  the  numerous  and  glaring  errors  mingled 
with  his  original  observations,  may  refer  to  Darcmberg,  Hist.  Gen.  des  Sc. 
Med.,  II,  p.  6-iO  seq.  He  believed  the  nerves  are  vessels  by  which  the  glands 
intercommunicate. 

^  Collect io  Disputationum  Medicarum,  VIII,  1663. 

*  Observationes  Anatomica,  Quibus  varia  Oris  Oculorum  et  Xarium  Vasa 
describuntur,  1662.  I  know  not  how  to  account  for  the  priorit}-  in  date  of 
Steno's  book  over  De  la  Boe's,  if  we  are  to  accept  Haller's  remark,  except  that 
the  teachings  of  the  latter  were  long  unpublished,  and,  indeed,  they  seem  much 
less  advanced  than  Steno's. 

*  Celsus,  Lib.  \ll,  Cap.  XII,  5. 


138  THE  PHARYNGEAL   TONSIL 

a  wider  observation  of  the  glands  to  the  works  of  the  more  original 
writers  just  mentioned. 

Havers  (1091)  supposed  the  spaces  known  by  his  name  which 
he  first  observed  in  bone  were  glands,  and  Pacchioni's  name  is 
attached  to  the  structures  in  the  dura  mater  wliich  he  believed  to 
be  glands  (1705). 

The  Microscope. — I  have  not  exhausted  by  any  means  the  indica- 
tions of  the  great  activity  in  the  latter  part  of  the  seventeenth 
century  in  the  anatomical  investigations  of  glandular  structures, 
made  jiossible  by  the  improved  microsco])e  of  Leeuwenhoek, 
though  it  was  ]Malpighi,  with  a  less  effective  lens,  in  spite  of  his 
egregious  blunder  as  to  the  brain,  who  first  demonstrated,  as  has 
been  said,  the  hollow  nature  of  the  conglomerate  glands  (1689). 
As  we  have  seen,  Van  Ruysch,  many  years  later,  attempted  to 
refute  this  opinion,  claiming  the  glands  were  bunches  of  minute 
bloodvessels,  as  Bellini  had  declared. 

The  old  compound  microscope,  said  to  have  been  first  suggested 
by  Zansz  in  1590,  was  a  very  imperfect  instrument,  and  about  a 
hundred  years  later  was  superseded  by  the  vastly  more  efficient, 
simple  high  curvature  lens  of  Leeuwenhoek,  with  which  he  studied 
the  capillary  circulation,  the  infusoria  and  a  host  of  other  hitherto 
unnoted  phenomena.  It  was  doubtless  with  such  a  magnifying 
glass  that  Santorini^  examined  the  glands  in  the  nasal  mucosa. 
"  If  we  wish  to  demonstrate  them  most  clearly  we  arrange  the 
membrane,  previously  cleansed  and  somewhat  macerated  under 
the  crystal,  and  the  light  being  conveniently  and  adequately 
arranged  for  it,  we  may  recognize  their  number,  their  size,  and 
their  color.  Their  size  varies  indeed,  some  being  a  little  ovoid, 
and  these  are  about  equal  to  a  grain  of  mustard." 

The  Pharyngeal  Tonsil. — Schneider^  gave  a  rather  poor  illustration 
of  the  pharyngeal  tonsil  and  thus  describes  it:  "It  is  of  a  whitish 
color,  the  adjoining  membranes  being  bloody  or  dusky.  It  is 
fuller  than  they  and  like  fat.  It  is  always  moist  and  exudes  a 
glutinous  substance."  He  located  very  definitely  this  posterior 
pituitary  membrane,  as  he  called  it,  as  existing  between  the  vomer 
and  the  foramen  magnum,  being  bounded  laterally  by  the  pterygoid 
plates.  This  being  Schneider's  description''  of  the  pharyngeal 
tonsil,  we  find  Santorini  describing  it,  as  he  did  the  glands,  much 
more  clearly  than  did  his  predecessors.  "This  membrane  I  have 
sometimes  met  arranged  in  shallow  grooves  (cavitates)  as  if  with 
some  kind  of  order.  Sometimes  I  have  found  it  in  irregularly 
arranged  forms  and  so  cavernous  that,  with  its  gaping  holes  and 

^  Observationcs  Anatomica;,  1724,  cap.  5. 

2  De  Catarrhis,  III,  Fig.  2. 

^  This  passage  may  perhaps  be  more  readily  referred  to  in  the  excerpt  made 

from  Schnrider's  text  in  the  footnote  to  the  first  page  of  Zuckerkandl's  Normale 
und  I'alhulogische  Anatomic  der  Nasenhohle,  2  Aufl.,  Wien,  1893,  I,  p.  1. 


THE  lATRO-FHYSICAL  AND  lATRO-CHEMICAL  SCHOOLS     139 

deep  sinuses  it  almost  equalled  the  tonsils.  From  this  a  mucous 
fluid  is  apt  to  exude."    Haller  also  described  this  oro;an. 

Notwithstanding  the  opposition  to  Schneider's  views  and  the 
persistence  of  the  old  pathology,  they  were  at  once  accepted  by 
many  distinguished  medical  writers.  Thus  we  find  Ettmiiller^ 
saying  in  1685:  "The  origin  of  all  catarrhs  is  the  conglomerate 
glands." 

The  Seventeenth  Century  Theories. — During  the  seventeenth  cen- 
tury we  hear  a  good  deal  about  vital  heat,  somewhat  equivalent, 
at  least  in  a  physical  sense,  to  what  we  now"  mean  by  animal  heat. 
This  was  connected  at  first  wdth  ideas  of  the  soul,  w^hose  habitat 
the  materialist  Descartes  fixed  in  the  pineal  gland,  which  was 
beginning  to  be  vacated  as  the  storehouse  for  nasal  secretion. 
This  "Vital  Heat"  was  an  outgrowth  of  the  "Pneuma"  of  the 
Ancients.  Gradually  the  true  idea  arose  out  of  this,  but  much 
later,  that  this  ^•ital  heat  depends  upon  chemical  action.  Before 
this  time,  under  the  old  theoretical  pathology  not  only  were  diseases 
hot  or  cold  or  wet  or  dry,  but  their  remedies  must  perforce  partake 
of  the  same  or  of  opposite  qualities.  It  is  very  difficult  for  the 
modern  student  of  medical  history  to  attempt  to  fathom  the 
reasons  for  according  these  properties  either  to  drugs  or  diseases. 
He  is  apt  to  regard  them  as  the  "ludibrium  ingenii  humani,"  but 
it  is  a  joke  spread  thick  over  the  broad  expanse  of  more  than 
twenty  centuries,  and  if  in  the  course  of  this  history,  \ery  little 
is  said  of  them,  it  is  not  because  they  do  not  start  from  the  page 
of  every  ancient  author  after  Galen. 

While  the  sixteenth  century  is  marked  in  medical  history  by 
great  advances  in  the  knowledge  of  gross  anatomical  facts,  the 
seventeenth  is  no  less  distinguished  by  the  elucidation  of  an  enor- 
mous amount  of  physiological  data.  This  we  have  seen  was  a 
logical  sequence,  and  as  we  proceed  we  will  perceive,  I  trust,  that 
the  pathological  observations  which  followed  in  the  eighteenth 
were  a  natural  outgrowth  of  physiological  activities  in  a  preceding 
epoch.  Medical  history  has  its  lessons,  no  less  useful  than  that 
of  the  rise  and  fall  of  empires. 

The  latro-Physical  and  latro-Chemical  Schools. — Sanctorius  (1516- 
1636)  who  had  witnessed  Galileo's  invention  of  the  thermometer 
improved  it  and  adapted  it  to  clinical  purposes.  The  influence  of 
the  philosophy  of  Descartes  had  resulted  in  the  advent  of  the 
latro-physical  school,  which  had  its  earliest  and  greatest  exponents 
in  Italy.  The  alchemists  and  Paracelsus  had  finally  subsided. 
Out  of  their  activities  was  brought  about  the  introduction  into 
medicine  of  a  more  or  less  rational  latro-chemical  school  which 
had  perhaps  a  wider  following.  We  recognize  the  importance  of 
the  observation  which  noted  the  change  in  the  color  of  the  blood 

1  Opera  Omnia:  Amst.,  1696-97,  II,  p.  740,  De  Catarrhis. 


140         THE  DISAPPEARANCE  OF  CHALDEAN   THERAPY 

in  the  transit  of  the  hnigs.  This  was  made  by  several,  among  them 
by  Lower,  who  in  anotlier  ])ubHcation  showefl  himself  the  adherent 
of  the  new  ideas  of  Schneider,  for  he  pnblished  in  1()71  a  "Dis- 
sertation on  the  origin  of  Catarrh  in  which  it  is  shown  that  it  does 
not  come  from  the  brain."  This  change  in  the  color  of  the  blood 
led  to  what  was  practically  the  discovery  of  Oxygen  by  Mayow, 
who  wrote  treatises  at  Oxford  in  1068  and  1074.  lie  identified  the 
gas  which  canses  this  change  as  nitre-air  or  aerial  spirit  and  as  the 
same  agent  which  supports  combustion. 

In  the  seventeenth  century  medical  monographs,  the  speciali- 
zation of  medical  literature,  became  more  numerous  and  instead 
of  weighty,  vohmiinous  tomes,  containing  all  the  wisdom  garnered 
from  all  the  fields  of  medicine  or  even  of  universal  science,  we  meet 
with  the  masterly  essays  of  Harvey  and  of  jNIalpighi.  We  more 
often  remember  the  fight  between  the  barber-surgeons  and  those 
w'ho  disdained  to  do  anything  but  observe  and  evolve  theories  of 
which  the  age  was  prolific.  These  are  only  a  few  hints  of  the 
broadening  of  knowledge  and  the  consequent  necessary  narrowing 
of  the  fields  of  individual  human  endeavor.  Many  old  errors  still 
lingered.  Van  Helmont  who  did  not  die  until  1044,  and  Willis 
who  was  not  born  until  1022,  when  Harvey  had  been  teaching  his 
doctrines  for  six  years,  still  conceived  of  the  air  as  passing  from 
the  air  channels  through  pores  into  the  thoracic  cavity.  (Sprengel 
IV,  180.)  As  far  back  as  the  time  of  Euclid  under  the  Ptolemies 
light  was  supposed  to  issue  from  the  eye  to  the  object.  Although 
this  was  corrected  by  the  Arabians,  mistaken  theories  still  pre- 
vailed, but  we  are  now  in  the  time  of  Newton  through  the  eft\ilgence 
of  whose  great  intellect  Medicine  was  guided  in  the  study  of  the 
physiology  of  the  eye. 

The  Disappearance  from  Medical  Literature  of  "Chaldean  Therapy." 
• — Far  beyond  the  period  of  the  early  llenaissancc  and  well  into 
the  seventeenth  century  may  be  found  the  recommendation  of 
stercoraceous  drugs  for  angina.  Hollerius,  writing  in  1023,  advises 
their  use  and  faithfully  transcribes  one  form  of  the  old  swallow 
prescription.  In  a  curious  old  l)ook,  a])])arently  for  home  use, 
published  in  1092  by  the  Hon.  R.  I^oyle,  Fellow  of  the  Royal  Society 
of  London,^  among  many  others  I  find  the  following  prescription: 
"Take  al)out  one  dram  of  Album  Grsecum  or  white  dog's  turd, 
burnt  to  perfect  whiteness,  and  with  about  one  ounce  of  Honey  of 
Roses,  or  clarified  honey,  make  thereof  a  linctus  to  be  very  slowly 
let  down  the  throat."  Many  better  known  writers  still  gave  them 
a  place  in  their  pharmacopa-ia.  Thus  we  find  the  prescrij)tion  of 
both  the  swallow  and  the  dog's  excrement  in  the  Bibliotheca 
Pharmaceutico  Medica  of  IMangetus.-    Gradually,  however,  much 

1  Medicinal  Experiments  or  Collection  of  Choice  and  Safe  Remedies.    London, 
1692-3,  II,  p.  165. 

2  Genevis,  1703,  I,  pp.  470,  982. 


THE  RESULTS  OF  THE  RENAISSANCE  141 

of  the  Chaldean  Pharmacopoeia  was  relegated  to  the  old-wives 
medicine  chest,  where  it  still  lingers,  supported  by  a  credulity  which 
has  not  all  taken  refuge  in  the  same  menage.  It  was  about  as  hard 
to  get  rid  of  this  sort  of  medication  as  it  was  to  introduce  a  more 
efficacious.  One  may  see  in  the  history  of  the  introduction  of 
quinine,  about  the  only  drug  which  we  have  that  really  cures  a 
disease  and  annihilates  its  cause,  how  rebellious  the  human  mind 
is  to  the  plain  demonstration  of  fact  in  therapeutics,  when  it 
contravenes  the  theoretical  doctrines  of  the  day.  The  Jesuits 
bark  crept  into  Europe  in  1638  and  the  orthodox  practitioner  of 
the  day  absolutely  rejected  it  and  for  a  time  left  its  employment 
to  be  mingled  with  the  hocus-pocus  of  priests  and  mountebanks. 
It  is  even  charged  against  our  profession  that  one  reason  for  the 
resistance  to  its  use  was  the  promptness  of  its  action  and  the 
simplicity  of  its  preparation  by  the  apothecaries,  intermittent 
fever  being  then  as  rich  a  mine  for  the  doctor  and  druggist  as 
phthisis  still  is. 

Amulets  and  charms,  it  is  true,  disappeared  from  medicine  soon 
after  the  beginning  of  the  Renaissance,  but  astrology,  out  of  which 
grew  the  discoveries  of  Copernicus  and  Galileo,  long  continued 
prominent  in  medical  thought  as  it  did  in  its  influence  upon  the 
actions  of  men.  Pope  Paul  III,  who  became  pontiff  in  1534, 
learned  as  he  was  in  Greek  and  Latin,  never  presumed  to  under- 
take the  smallest  personal  business  nor  engage  in  the  weightiest 
affairs  of  state  without  first  consulting  the  stars.  Two  hundred 
years  later  we  shall  find  a  grave  doctor  discoursing  on  the  influence 
of  the  moon  on  nasal  polypi. 

Soon,  however,  among  men  of  science  astrology  became  astron- 
omy, alchemy  became  chemistry,  and  therapeutics  soon  began  to 
look  to  physiology  and  pathology  for  help. 

THE  RESULTS  OF  THE  RENAISSANCE. 

It  is  unnecessary  to  enter  further  than  we  have  already  done 
into  an  account  of  the  collateral  events  in  the  development  of  our 
knowledge  of  the  nose  and  throat.  The  facts  brought  to  light 
were  numerous.  Scarcely  less  abundant  were  the  theories  to 
account  for  them.  Through  this  maze  of  truth  and  error  we  must 
try  to  trace  the  thread  of  our  own  story.  To  take  this  up  we 
must  return  to  the  period  succeeding  the  revival  of  anatomical 
learning,  in  order  to  see  the  effect  it  had  on  the  ideas  concerning 
the  nose  and  throat  and  their  treatment.  It  is  of  only  incidental 
interest  to  remark  here  that  the  first  separate  treatise  of  laryngeal 
disease  I  have  met  with  is  that  of  Codronicus'  "De  Vitiis  ^\)cis," 
published  in  1597.  It  contains  nothing  of  value,  being  a  faulty 
copy  of  Galen's  ideas.  It  is,  however,  significant  of  the  tremendous 
amount  of  pulj)it  oratory  which  was  going  on  then,  often  perhaps 


142  THE  RESULTS  OF  THE  RENAISSANCE 

under  circumstances  very  trying  to  the  organ  of  the  voice,  to  find 
the  author  on  the  first  of  his  147  pages  declaring  tliat  he  writes 
the  book  for  the  good  of  the  preachers  of  the  Holy  Word.  This 
I  believe  is  not  now  to  be  found  in  the  prefaces  of  text-books  on 
the  larynx.  Very  little  perusal  of  it  will  reveal  evidence  that 
clergyman's  sore  throat  was  then  well  known. 

Sixteenth  Century  Practice. — A  little  before  this,  in  1591,  Forestus, 
a  very  voluminous  but  a  perspicuous  writer,  devoted,  in  his  works, ^ 
3(X),  12  mo,  pages  of  fine  ])rint  to  the  diseases  of  the  nose  and 
throat.  In  regard  to  anosmia  he  says:  "If  it  is  from  ethmoidal 
obstruction,  or  from  the  humor  discharged  from  a  catarrh,  the  latter 
must  first  be  cured.  (By  ethmoidal  obstruction  he  docs  not  here 
mean  the  stoppage  of  the  holes  in  the  cribriform  plate.)  If  from 
flesh  growing  within  the  nose,  or  from  a  wart  or  a  hemorrhoid,  it 
is  to  be  cured  by  the  surgeons  by  operative  procedures,  either  with 
a  cutting  instrument  or  cautery  or  snare."  All  of  which  is  good 
treatment,  but  then  follow  therapeutic  measures  based  on  pre- 
Schneiderian  anatomy:  "If  from  an  abundance  of  humours  filling 
the  ventricles  of  the  brain  or  obstructing  the  sieve-like  openings, 
it  is  to  be  carried  ofT  by  the  letting  of  blood,  or  by  purging."  The 
cautery  is  often  mentioned  with  recommendations  not  only  for  its 
intranasal  use,  but  as  a  remedy  in  nasal  disease  to  be  applied  to 
the  cranial  bregmata  and  the  posterior  cervical  regions,  a  method 
of  treatment  we  have  noted  in  Herodotus  as  existing  among  the 
Libyans,  for  the  prevention  and  cure  of  coryza  and  catarrh.  Indeed, 
his  therapy  seems  a  queer  mixture,  some  of  it  taken  from  hoary 
antiquity,  while  some  of  it  bears  favorable  comparison  with  modern 
treatment.  He  claims  to  have  cured  a  girl  of  ozsena  by  copious 
nasal  douching  " with  perfumed  white  wine  in  which  were  dissohed 
cypress,  roses,  and  myrrh."  He  also  used  nitrate  of  silver  and  ahnn 
rubbed  up  with  honey  and  applied  with  a  pn)be.  We  are  a  little 
shocked  to  find,  farther  on,  that  he  cured  another  by  bleeding, 
purging,  cupping,  diet  for  six  weeks,  and  administering  a  decoction 
of  guaiac.  Forestus  dwells  on  the  ravages  of  nasal  syphilis,  which 
prefers  attacking  the  bone  to  the  soft  parts,  and  he  reminds  us 
that  not  everv  ulcer  in  the  nose  is  ozsena,  for  often  ulcers  arise 
from  a  salty  mucus  which  produces  crusts,  and  these  are  easily 
cured.  We  find  this  crude  i)ath()logy  at  a  much  later  date.  Boer- 
haave  declared  (1C6S-1738):  "This  mucus,  being  also  corrupted, 
produces  an  ulcer  which  corrodes  the  adjacent  bones."  Of  course 
oz£ena,  after  the  advent  of  syphilis,  was  frequently  confounded 
with  it. 

Dry  Heat  in  the  Therapy  of  Ozsena. — We  may  note  here  the  method 
of  treating  ozaena  detailed  by  Fabricius  ab  Acquapendente-  who 

'  Observationum  et  Curationum  Mcdicinalium  Libri.  Ludg.  Batav.,  1591, 
Lib.  XIII-XV. 

-  Opera  Chirurgica;  De  Chirurgicis  Operationibus,  Lugtl.  Batav.,  1723,  Cap. 
XXVI,  p.  445. 


TONSILLAR  HYPERTROPHY  143 

wrote  about  the  same  time  as  Forestus,  but  whose  works  are  of 
much  more  importance  in  the  history  of  medicine.  After  criticising 
the  treatment  of  Celsus,  he  savs:  "AYherefore  I  offer  vou  a  similar 
surgical  procedure  in  ozaena,  but  a  far  milder  one.  An  iron  cannula 
is  to  be  inserted  in  the  nostril,  so  long  that  it  will  reach  the  end 
and  equal  the  length  of  the  ulceratif)n  and  occupy  the  cavity  of 
the  nostrils;  through  this  a  glowing  hot  instrument  is  to  be  intro- 
duced, which,  however,  should  not  reach  beyond  the  cannula;  it 
should  be  so  done  that  the  hot  iron  heats  the  tube,  and  through 
this  the  nasal  tissues  and  the  ozaena;  it  is  not  intended  that  the 
nose  should  suffer  pain  from  this  heat,  but  only  that  the  ulcerated 
part  should  be  heated  to  a  point  short  of  pain  (citra  dolorem), 
in  one  having  a  good  tolerance.  This  being  perceived  the  cannula 
may  be  taken  out  of  the  nostrils,  the  secretions  cleaned  off  and  then 
replaced."  This  was  to  be  repeated  as  often  as  necessary  until 
the  part  was  thoroughly  cleansed  of  crusts,  the  mucous  membrane 

Fig.  9 


The  nasal  cauteries  of  Dionis. 

made  red  without  the  pain  of  burning,  the  secretions  stimulated, 
and  thus  the  ulcer  healed.  Dionis  much  later  (1707)  followed 
practically  the  same  method,  and  I  am  sure  every  modern  rhinolo- 
gist  will  appreciate  the  value  of  the  suggestion.  Dionis  used  a 
cannula  closed  at  one  end. 

Tonsillar  Hypertrophy. — Forestus^  referred  to  the  tonsils,  inider 
the  heading  of  Inflammation  of  the  Glands,  as  small  caruncles,  which 
all  men  have  at  the  back  of  the  mouth  on  each  side.  His  method 
of  treating  hypertrophies  in  this  situation  in  a  young  girl  of  eighteen 
was  atrocious.  She  was  nearly  suffocated  with  large  tonsils,  and 
had  never  menstruated.  He  administered  the  extract  of  swallow's 
nest  (one  could  make  a  homoeopathic  pun  on  it  in  English  but 
not  in  Latin)  and  gave  her  urine  to  drink.  Bleeding  and  cupping 
were  vigorously  used  and  after  five  days  "  in  spite  of  the  treatment 
she  fell  into  a  deliquium  animi,"  which  he  ascribed  to  "uterine 
suffocation."  He  then  quotes  Aetius  as  saying  on  the  authority 
of  Archigines:   "]\Iany  virgins  at  the  age  of  puberty,  lacking  their 

'  L.  c.  Lib.  15,  obs.  VII. 


144  THE  RESULTS  OF  THE  RENAISSANCE 

menses,  are  seized  with  this  afleetion."  This  differs  from  modern 
ideas,  whose  interpretation  would  be,  "Many  virgins,  at  the  age 
of  puberty,  hick  their  menses,  because  they  are  seized  with  this 
affection."  Elsewhere  he  dilates  on  the  virtues  of  the  stercor- 
aceous  drugs  in  affections  of  the  tonsils.  Farther  on  we  shall 
have  to  refer  to  the  first  account  of  an  epidemic  of  diphtheria  by 
Forestus,  but  in  his  chapters  on  the  Nose  and  Throat  we  find  plen- 
tiful evidence  of  sporadic  cases,  unflitt'erentiated  from  other  throat 
infiannnations,  and  we  read^  a  graphic  description  of  the  death 
of  his  own  father  from  laryngeal  stenosis,  without  apparently  the 
thought  of  a  tracheotomy,  though  he  was  perfectly  familiar  with 
the  descrii)tion  of  it  by  Paulus.  Cynanche,  paracynanche,  and 
cynanche  with  phlegmonous  facial  erysipelas  are  terms  which  still 
remind  us  that  the  frequency  of  that  type  of  disease  must  have 
then,  as  in  the  time  of  Hippocrates,  been  greater  than  now,  perhaps 
from  personal  imcleanliness  and  the  greater  exposure  thereby  to 
septic  influences. 

Fabricius  ab  Acquapendente,  after  describing  the  operation  of 
tonsillotomy  as  performed  by  Celsus  and  Paulus  Aegineta,  says: 
"  Wherefore  we  mav  gather — that  it  is  neither  entirclv  easv  nor 
safe  to  carry  out  the  operation."  Consequently  he  advises  "seizing 
the  tonsil  with  a  long,  slender  forceps  to  draw  it  out  so  that  by 
skilfully  making  traction  the  tonsil,  as  if  of  its  own  accord,  will 
follow.'-  There  is  another  Fabricius,  from  whom  much  may  be 
learned  regarding  the  surgery  of  the  throat  at  this  time. 

The  Uvula. — Fabricius  Hildanus^  relates  the  case  of  a  young  man 
with  such  a  hypertrophied  and  elongated  uvula  that  it  nearly 
filled  the  mouth  and  touched  the  teeth.  It  was  so  large,  swollen 
and  vascular,  they  were  afraid  to  operate,  and  sent  the  man  home 
to  die,  as  they  thought.  On  a  less  dangerous-looking  condition, 
in  another  patient,  he  advised  operation.  In  a  third,  the  growth 
seemed  malignant,  and  he  left  it  alone.  For  the  insufflation  of 
powders  which  he  used  in  these  and  other  cases  he  devised  a 
powder  blower  (Fig.  10).  The  tip  of  the  uvula  was  engaged  in 
the  cup,  and  powder  was  thus  thoroughly  blown  on  it.  If  the 
relaxation  and  inflammation  of  the  uvula  did  not  yield  to  these 
measures,  it  was  to  be  cut  off  with  the  scissors,  or  ligated,  or 
burned  with  caustic.  For  tying  the  ligature  he  used  an  instru- 
ment which  was  long  in  vogue  (Fig.  11).  He  used  another 
instrument  for  applying  the  actual  cautery  to  the  organ.  Tt 
consisted  of  a  long  cannula,  fenestrated  at  one  end.  The  u\'ula, 
engaged  in  tins  a])erturc,  was  l)urned  with  the  hot  iron  thrust 
through  the  open  end,  the  other  being  closed.  Following  Galen, 
though  the  operation  was  done  frequentl\',  it  was  always  performed 

1  Lib.  XV,  Obs.  XV.     (Scholia.) 

-  Opera  Chir.,  De  Chir.  Oporat.,  Cap.  XXXVIII,  p.  4()2. 
^  ObKorvatioiiuin  ot  Curationum  Chirurgicanun  Centuria  II.     Opera  Omnia, 
1646,  Obs.  XIX. 


TOBACCO   THEKAI'Y 


145 


with  a  good  deal  of  caution,  as  may  be  seen  by  referriiiii;  to  the 
earlier  work  of  Pare,^  where  instruments  similar  to  those  of  Ilildanus 
are  figured.  Fabricius  ab  Acquapendente  (1.  c.)  boasted  that  his 
dexterity  was  so  great  he  did  not  have  to  use  a  forceps  in  cutting 


Fig.   10 


The  powder  blower  of  Fabricius  Hildanus  for  the  uvula. 

Fig.  11 


Tlie  uvulotome  of  Fabricius  Hildanus. 

off  the  uvula,  but  depressing  the  tongue  with  one  hand  he  u.sed 
the  scissors  with  tlie  other. 

Tobacco  Therapy. — The  latter  author,-  who  must  have  written 
it  about  !()()(),  makes  an  interesting  mention  of  tobacco  in  intra- 

'  Les  ffiuvres  d'Anibroise  Pare.     Lyon,  (ire^oire,  l(U)-4,  p.  ISO. 
^  L.  c.  De  Suffuinigio  Aiif^lico  ex  Tabaco,  et  Chirurgia  Naso  Uriciue  Cominuni. 
Cap.  XXVII,  p.  447. 
10 


146  THE  RESULTS  OF  THE  RENAISSANCE 

nasal  treatment.  Sir  "Walter  Raleigh  had  brought  the  knowledge 
of  the  weed  to  England  several  years  before,  but  he  does  not 
seem  to  have  used  a  pipe  for  smoking  it  until  after  the  return  of 
Sir  Francis  Drake  in  15SG  (Lizars).  Fabricius  says:  "They  are 
accustomed  in  England  to  prepare  a  fumigation  from  tobacco  or 
herba  regina  exisiccata,  the  smoke  of  which  when  ignited  they 
draw  through  a  slender  pipe  into  the  mouth,  and  by  this  the  mouth 
])eing  filled,  so  that  the  cheeks  are  inflated,  it  comes  out  of  the 
nostrils.  In  England,  as  I  have  said,  it  is  most  frequently  used, 
and  with  the  happiest  results."  Gregory  Horst,^  who  wrote  about 
the  same  time,  and  was  enthusiastic  as  to  the  medicinal  properties 
of  tobacco  in  the  treatment  of  catarrh  and  coryza,says:  "Indeed, 
the  smoke  of  this  ignited  plant  taken  into  the  nose  and  mouth 
seems  to  benefit  them,  so  that,  as  it  were,  by  its  resolving,  cutting, 
and  attenuating  properties  it  causes  the  secretion  and  consumption 
of  the  mucus  and  viscid  humors.  For  which  reason,  authors 
declare,  the  inhabitants  of  Florida,  at  certain  specified  seasons  of 
the  year,  live  on  the  smoke  of  this  j)lant,  which  they  receive  into 
their  mouth  through  horns  prepared  for  this  purpose,  whereby, 
they  assert,  thirst  and  hunger  are  stilled,  and  an  incredible 
amount  of  phlegmatic  humors  are  collected  in  the  mouth."  So 
beneficial  was  this  that  some  called  it  the  ".holy  plant"  or  petum 
or  the  Queen's  plant.  "When  it  is  taken  into  the  mouth  through 
a  pipe-stem,  it  pervades  the  whole  brain,  and  in  the  same  manner 
is  borne  into  the  ears  and  even  the  uterus.  One  of  the  signs  of 
its  efficacy  is  the  paleness  of  the  countenance."  One  may  easily 
perceive  traces  of  the  experience  of  the  first  European  novice  to 
follow  this  curious  habit  observed  in  the  new  world.  The  old 
smoker  needs  only  to  recall  his  first  ])ipe  to  understand  the  awe 
wdth  Avhich  the  first  white  man  looked  upon  the  potency  of  the 
new  drug.  The  perusal  of  the  literature  concerning  the  medicinal 
virtues  of  tobacco  in  Queen  Eliza])eth's  time  should  furnish  a 
fruitful  source  for  reflection  to  those  apt  to  be  enthusiastic  over 
new  drugs.  Pursuing  this  line  of  thought,  I  may  be  allowed  to 
insert  a  citation,  not  from  the  veracious  history  of  Diedrich  Knick- 
erbocker, but  from  sombre,  musty,  medical  annals.  Bontekoe, 
a  FloUand  sage  whose  singular  name,  "pretty  cow,"  would  attract 
attention  without  the  knowledge  of  his  other  peculiarities,  was  so 
impressed  with  the  virtues  of  the  products  his  countrymen  were 
bringing  from  the  West  and  the  East  Indies,  as  to  declare  there 
was  nothing  so  conducive  to  long  life  and  rol)ust  health  as  smoking 
countless  pipes  of  tobacco,  and  drinking  iiummerable  cups  of  tea. 
Syphilis. — Whatever  may  be  our  belief  as  to  the  existence  of 
syphilis  in  the  ancient  world  and  in  the  Middle  Ages,  none  can 

^  Gregorii    Horstii    Senioris   Opera    Medica,    Cent.    Problem.      Therapeut., 
Decas  III,  Quaestio  VII,  Goudae  and  Amst.,  1661,  Tom.  Ill,  p.  47. 


PROSTHESES  147 

deny  that,  if  we  are  to  judge  alone  from  the  medical  literature  of 
the  day,  apparently  in  the  latter  part  of  the  fifteenth  century, 
possibly  before,  certainly  after  the  return  of  Columbus'  sailors, 
syphilis  spread  rapidly  throughout  Europe.  The  profligacy  of 
the  times,  the  wars  of  Italy,  the  indescribable  misery  and  filth  of 
the  people,  the  wandering  priests,  jongleurs,  beggars,  and  robbers 
have  been  collected  by  the  medical  historian  into  a  picture  to 
explain  the  reason  for  the  birth  of  many  new  diseases,  which 
appeared  first  during  the  fifteenth  and  sixteenth  centuries,  but 
all  these  pretended  causes  had  existed  for  a  thousand  years. 
Columbus  did  not  bring  with  him  whooping  cough,  scarlet  fever, 
diphtheria,  and  influenza.  These  all  appeared,  possibly  with  the 
exception  of  the  last,  to  have  arisen  during  the  Renaissance  of 
learning  in  Europe.  It  is  difficult  to  be  sure  of  the  origin  of  any 
of  them,  but  we  may  conjecture  that  all  had  previously  existed 
and  that  the  awakening  of  scientific  observation  at  this  time  first 
brought  about  the  literature,  upon  which  we  depend  for  their 
identification  in  modern  nosology. 

It  is  only  the  strikingly  specific  phenomena  of  diphtheria  which 
permit  our  recognizing  it  in  the  works  of  Aretaeus  and  Galen. 
Syphilitic  lesions  with  their  multiform  and  deceptive  resemblances, 
with  the  insignificance  of  the  initial  lesion,  may  easily  have  been 
classed  with  the  various  affections  which  are  at  present  grouped 
dift'erentlv.  It  has  onlv  been  within  the  last  hundred  years  that 
tertiary  syphilitic  laryngitis  has  been  separated  from  tubercular, 
both  being  included  by  jMorgagni,  Louis,  Trousseau,  and  Belloc, 
under  the  heading  of  laryngeal  phthisis.  There  is  no  one  word 
that  is  so  comprehensive  in  its  significance,  when  applied  to  the 
advance  of  knowledge  in  the  history  of  medicine,  or  indeed  in 
the  history  of  all  sciences,  as  dift'erentiation,  and  this  one  word,  I 
believe,  will  explain  the  birth  of  many  so-called  new  diseases  in 
medical  annals.  We  can  only  conjecture  that  this  holds  true  as 
to  syphilis. 

We  have  noted  Berengar,  reaping  a  rich  harvest  with  the  mer- 
curial treatment  of  syphilis  among  the  ecclesiastics  in  Rome,  and 
we  can  scarcely  peruse  a  medical  book,  published  after  1500,  that 
we  do  not  find  abundant  evidences  of  the  ra^'ages  of  the  disease, 
often  unrecognized  in  its  extragenital  lesions.  Sunken  noses, 
perforated  palate  bones,  laryngeal  stenosis  are  forced  on  our 
attention.  Forestus,  who  was  familiar  with  the  ravages  of  nasal 
syphilis,  vividly  describes  the  syphilitic  ulcerations  of  the  soft 
palate,  recognizing  the  condition  in  a  case  he  details,  "though  the 
noble  youth  denied  it." 

Prostheses. — Various  devices  soon  came  into  use  for  remedying 
the  results  of  syphilitic  ulcerations.     Palfin^  says  that  Amatus 

'  Anutomia  Cliirurgica. 


148  77/ /s    RESFLTS  OF   THE  REXAISSANCE 

Liisitanus,  a  Portuguese  Jew,  who  was  horn  in  loll,  and  who 
succeeded  in  eluding  the  clutches  of  the  Inquisition,  invented  an 
instrument  "which  is  a  blade  of  silver  in  the  middle  of  which  there 
is  a  hole,  and  through  this  a  piece  of  sponge  may  l)c  jiassed  and 
fastened  firmly  to  the  metal  i)latc.  This  is  then  ap])lied  to  the 
perforation  of  the  palate  in  such  a  way  that  the  sponge  swelling 
with  the  humidity,  the  plate  is  held  so  firmly  against  the  palate, 
and  closes  so  exactly  the  opening,  that  it  only  can  be  detached 
with  difficulty."  Pare  and  Fabricius  Ilildanus  also  s])eak  of  a 
similar  prosthesis.  Pare  indeed  it  was  who  is  said  to  iiave  first 
performed  the  operation  of  staphylorrhai)hy.  Although  he  was 
familiar  with  the  operation  of  Tagliacozzi,  he  suggested  in  cases 
of  loss  of  the  external  nose  the  use  of  an  artificial  one  in  the  form 
of  a  mask.^  Although  Pare's  treatment  of  a  fractured  nose  was 
far  inferior  to  that  of  Hii)pocrates,  he  figured  the  hollow  splints 
he  used,  and  elsewhere  he  says:  "Now  it  is  well  to  understand 
that  the  solution  of  continuity  occurring  in  the  cartilage  is  called 
fracture  by  Hippocrates,  like  those  of  the  bone,  because  he  had  no 
other  name  to  express  it  better." 

Rhinoplasty. — In  Celsus-  plastic  operations  on  the  nose  are  very 
superficially  noted,  and  the  same  may  be  said  of  Galen  (Isagoge) 
and  of  Paulus  Aegineta  (^T,  26).  The  Arabians,  in  spite  of  their 
communication  with  India,  and  their  opportunity  of  acquiring 
some  of  the  medical  knowledge  of  that  ancient  land,  do  not  appear 
to  have  left  any  records  of  Rhinoplasty  in  their  works.  This  is 
the  more  surprising,  because  there  is  every  reason  to  believe,  as 
von  Graefe  asserts,  that  the  Saracens  introduced  the  art  into 
Sicily.^  With  such  a  degree  of  skill  were  some  of  the  Oriental 
practitioners  credited,  that  tales  were  told  in  the  ^Jiddle  Ages, 
and  even  at  a  later  date,  of  the  executioners  throwing  freshly 
amputated  noses  into  the  fire,  that  they  might  not  be  })icke(l  up 
by  friends  and  relations  of  the  victim  and  afterward  sewed  in  j)lace. 
Slaves,  it  is  said,  were  in  Sicily  compelled  to  surrender  their  noses, 
at  times,  to  masters  who  in  the  vicissitudes  of  the  times  had  lost 
their  own.  A  slight  perusal  of  the  history  of  Sicily  will  convince 
anyone  that  this  interchange  of  commodities  might  have  been 
brisk,  as  an  ordinarily  active  man  might  easily  be  master  and 
slave  several  times,  in  the  course  of  a  moderately  long  life.  There 
is  a  record  of  Branca'  having  made  a  new  nose  as  early  as  1442, 
and  he  is  said  to  iiave  been  preceded  by  even  earlier  surgeons. 
Branca,  the  father,  made  a  nose  of  the  neighboring  parts  of  the 

'  Ofuvrt'.«.    Livrc  XXIII,  Cup.  2. 

-"  Do  Modicina  Lib.  VII,  Cap.  IX. 

■'For  a  more  extensive  bihlioj^raphy  see  Cloquet:  OsphrAsiologio.  Von 
Graefe:  De  Rhinoplastice,  Berlin,  1818.  Zeis:  Die  Lileratur  und  Ceschichte 
der  Plastischen  Cliirurgie,  1863.  John  Hamilton:  The  Restoration  of  a  Lost 
Nose,  London,  1864. 

^  For  reference  to  an  old  manuscript  describing  the  rhinoplasty  of  Branca, 
father  and  son,  see  Gurlt:   Geschichte  der  Cliirurgie,  II,  i).  489. 


RHINOPLASTY  149 

face,  but  his  son  Antoniiis  used  the  skin  of  the  forearm.  The  art 
seems  also  to  have  been  practised  in  Sicily  in  the  sixteenth  century 
by  a  family  of  the  name  of  Vianeo. 

Baas  remarks  "that  syphilis,  and  a  nose-destroying  pope,  who 
fixed  upon  amputation  of  the  nose  as  a  punishment  for  larceny, 
afforded  the  most  frequent  occasion  for  these  rhinoplastic  opera- 
tions." He  refers  to  much  later  times,  viz.,  the  pontificate  of 
Sixtus  V  (1585-1590).  Earlier  than  this,  Lanfranc,  Cauliac, 
Cerlata,  and  other  surgeons,  refused  to  believe  these  marvellous 
stories  from  Sicily,  but  the  operation  is  mentioned  before  Taglia- 
cozzi  published  his  work  (1597),  by  Vesalius,  Fallopius,  Paracelsus, 
and  others.  Benedetti,  who  died  in  1525,  is  said  to  have  been  the 
first  in  Europe  who  speaks  of  artificial  restoration  of  the  nose, 
except  those  authors  who  ridiculed  the  possibility  of  it.  I  have 
mentioned  Fare's  idea  of  an  artificial  nose.  Tycho  Brahe,  the 
early  astronomer,  a  choleric  philosopher,  in  15GG  lost  his  nose  in 
a  duel,  and  is  said  to  have  supplied  the  defect  so  skilfully  with 
gold,  silver  and  wax  it  was  scarcely  noticeable.  Fabricius  Hildanus,^ 
in  a  letter  to  Grifi'onius,  speaks  of  having  seen  a  case  in  which  the 
nasal  organ  had  been  restored  by  operation,  after  the  method  of 
Tagliacozzi,  and  from  Grifi'onius'  reply,  we  learn  that  he  himself 
had  learned  the  method  from  Tagliacozzi  on  one  of  his  many 
journeys.  Such  a  triumph  of  the  surgeon  was  attained  in  this 
case,  referred  to  by  Hildanus,  that  the  young  lady  who  hatl  her 
features  corrected  by  the  method  of  Tagliacozzi  was  married  within 
a  year.  This,  and  many  other  such  references  in  the  literature 
of  the  time,  indicate  that  to  the  latter  is  due  the  credit  of  having 
brought  the  method  in  \'ogue  on  the  continent,  though  his  book'^ 
was  not  published  until  long  after  the  operation  was  well  known. 
His  operations  were  elaborate  and  ingenious.  He  used  not  only 
the  adjacent  parts  of  the  face  in  the  repair  of  the  nose,  but  the 
skin  of  the  arm,  having  apparently  derived  the  idea  from  his 
knowledge  of  tree  grafting.  His  restorations  of  the  ears  and  lips 
were  not  less  admirable  and  ingenious.  Such  operations  have 
always  excited  much  merriment  among  the  wits  of  the  laity,  and 
we  find  Butler,  in  his  famous  "Hudibras,"  declarhig: 

"So  learned  Taliacotius,  from 
The  brawny  i)art  of  porter's  bum, 
Cut  supplemental  nose.s,  which 
Would  last  as  long  as  parent  breech; 
But  when  the  date  of  Nock  was  out 
Off  dropped  the  sympathetic  snout." 

Van  Helmont^  gravely  supplies  science  with  the  account  of  this 
tragic  episode:     "A  citizen  of  Ikussels,  having  lost  his  nose  in  a 

1  Opera  Omnia,  Franeof.,  1G46,  Obs.  ;^1,  p.  214;  also  Epist.  62,  p.  1006. 

^  De  Curtorum  C'hirurgia  i)er  Insitiouem,  sen  de  Xarium  et  Aurium  Defectu 
per  Insitionem,  Arte  hactenus  ignota  sarciendo,  V'enetiis,  1597. 

5  De  Magnet,  Vuln.  Curat.,  22,  in  his  Opera  Omnia,  Franeof.,  1682,  p.  707; 
Ref.  Daremb.  (1.  c.),  I,  477. 


150  THE  RESULTS  OF  THE  RENAISSANCE 

fight,  applied  to  a  surgeon,  named  Tagliaeozzi.  The  latter,  in 
order  to  cure  him  without  resulting  deformity,  made  use  of  auto- 
plasty,  and  borrowed  a  strip  of  flesh  from  the  arm  of  a  servant. 
The  wounded  man  returned  home  with  his  borrowed  nose.  Thirteen 
months  later  he  was  all  at  once  disagreeably  surprised  to  find  the 
organ  growing  cold  and  becoming  gangrenous.  What  had  hap- 
pened? After  much  lamentation  and  inquiry  it  was  learned  that 
the  servant  from  whose  arm  the  nose  had  been  taken  at  Brussels 
had  died  exactly  at  the  time  the  nose  began  to  grow  cold.  .  .  . 
There  are  eye  witnesses  at  Brussels  of  this  fact." 

In  the  Tattler,  No.  260,  Addison  continues  to  make  merry  over 
the  misfortunes  of  the  early  victims  of  syphilis,  pointing  out  how 
appropriate  it  was,  in  the  painting  of  Corregio,  to  represent  the 
dimpled  God  of  Love  taking  lessons  in  archery  from  ^lercury. 
He  affirms  that  his  arrows  were  dipped  in  poison  and  the  boy 
aimed  them  at  his  quarry's  nose,  not  his  heart.  Taliacotius  was 
the  first  "clap-doctor,"  whom  Addison  had  met  with  in  history, 
and  was  very  celebrated,  but  he  had  made  the  awkward  mistake, 
in  the  case  referred  to  in  "Hudibras,"  of  grafting  on  a  swarthy 
Portuguese's  features  epidermis  removed  from  that  part  of  the 
anatomy  of  a  fair-skinned  German  which  is  not  exposed  to  the 
sun's  rays.  There  is  much  more  of  this  sort  of  banter,  which  seems 
to  have  been  acceptable  to  the  readers  of  this  classic  English  author 
in  his  day.  In  spite  of  such  indelicate  but  merry  satire  of  this 
kind,  so  brilliant  were  Tagliacozzi's  real  results  that  the  theologians, 
continually  on  the  alert  for  that  sort  of  alliance  in  others,  considered 
him  in  league  with  the  devil,  or,  at  least,  exceedingly  impious  in 
presuming  to  engage  in  a  work  they  were  bold  enough  to  ascribe 
exclusively  to  the  Almighty.  Some  nuns  declared  after  his  death 
(1599)  they  heard  a  voice  exclaiming  that  he  was  damned,  so  they 
dug  up  his  body  from  consecrated  ground  and  cast  it  out.  There- 
upon his  colleagues  in  the  anatomj^  school  of  Bologna  raised  a 
statue  to  him,  where  he  stands  immortalized,  a  nose  in  his  hand. 
(Whittington.) 

Epidemics  of  Influenza. — Having  noted  the  advent  of  syphilis 
in  medical  history,  and  its  influence  upon  the  diseases  of  the  nose 
and  throat,  we  now  take  account  of  the  other  contagious  diseases 
which  become  prominent  in  the  records  at  this  time.  Except  for 
accounts  of  sporadic  cases  of  diphtheria,  which  we  are  able  to 
recognize  in  the  very  oldest  records  of  medicine,  reports  of  influenza, 
unnoticed  by  the  Greeks  and  Romans  and  Arabians,  were  the  first 
to  emerge  from  the  obscurities  of  the  Dark  Ages.  Professor 
Eugene  Mittwoch^  thinks  he  has  reason  to  infer  that  in  the  annals  of 
the  Arabian  writer,  Ilamza  Ispahan-  there  is  reference  to  the  occur- 
rence of  an  epidemic  of  influenza  in  Arabia  in  the  year  871  a.d. 

'  Berliner  klinische  Woch.,  No.  10,  March  10,  191.3,  L,  p.  447. 
2  Annalium  libri,  X,  Ed.  J.  M.  E.  Gottwaldt,  Petropoli,  1844. 


EPIDEMICS  OF  INFLUENZA  151 

It  rests,  however,  upon  the  evidence  of  a  passage  which,  though 
it  may  be  interpreted  in  that  way,  is  hardly  definite  enough  to 
warrant  impHcit  behef  in  the  inference.  While  Creighton^  makes 
a  doubtful  reference  to  the  disease,  reported  as  early  as  1173  a.d., 
Ozanam-  says  of  catarrhal  fever:  "One  of  the  oldest  epidemics 
of  this  time,  of  which  there  is  no  mention  since  the  beginning  of 
the  Christian  era,  is  that  of  the  month  of  August,  1239,  which  one 
finds  noted  in  the  chronicles  of  the  Freres  Mineures.  The  same 
chronicle  speaks  of  another  in  1311  in  France,  where  many  perished 
from  it."  He  speaks  of  it  as  occurring  in  Florence  in  1323,  through- 
out all  Italy  in  1327,  and  there  was  another  epidemic  in  1358, 
again  in  1387  and  1400.  In  France  records  report  it  in  1403,  1410, 
1411,  1414,  1427,  1438,  1482,  1505.  Creighton  finds  traces  of  it 
as  occurring  in  England  during  the  reign  of  Henry  VI  (1427).  If 
it  is  really  influenza  which  is  referred  to,  according  to  Creighton, 
by  Rodolphus  de  Diceto  as  occurring  in  1173,  we  may  see  from 
the  phrase  "Universus  orbis  infectus  ex  aeris  nebulosa  corruptione," 
that  his  idea  of  the  etiology  was  quite  excusable.  Anglada^  quotes 
Felibien  as  follows:  "In  1414  there  prevailed  a  north  wind  so 
contagious  that  it  caused  a  very  frequent  disease  which  they 
called  'coqueluche,'  'the  tac'  or  'the  horion.'  It  was  a  kind  of  a 
cold,  which  caused  such  hoarseness  that  the  Parlement  and  the 
Chastelet  were  obliged  to  interrupt  their  sessions.  There  was  loss 
of  sleep,  great  pains  in  the  head,  in  the  loins,  and  throughout  the 
rest  of  the  body;  but  the  disease  was  not  mortal  except  in  old 
people."  The  French  names  for  it  were  influenza,  coquette, 
petite-poste,  follette,  horion,  tac,  grippe.  The  word  influenza 
was  not  adopted  in  England  until  1743,  the  early  English  designa- 
tion being  "mure"  or  murre,"  probably  from  the  same  root  as 
"murrain."  It  was  occasionally  called  "the  new  disease."  De 
Thou  in  his  Universal  History  speaks  of  it  as  occurring  in  1580* 
thus:  "A  new  disease,  called  in  Italy  vervecinus  (pertaining  to  a 
sheep  or  a  wether)  which  first  proved  deadly  in  the  East,  then  in 
Italy  and  later  in  Spain;  for  from  this  Anna,  the  wife  of  King 
Philip  (II  of  Spain),  died,  and  Gregory  XIII  (who  reformed  the 
calendar)  was  dangerously  ill  with  it."  It  is  probable  that  King 
Philip  had  also  been  ill  with  it,  for  we  read  in  Prescott  an  affecting 
account  of  his  devoted  Queen,  his  third  consort,  praying  that  he 
might  be  spared  and  she  taken,  a  supplication  which  was  granted. 
De  Thou  speaks  of  the  astounding  rajoidity  of  the  progress  of  the 
disease,  and  enumerates  some  of  its  striking  symptoms.     He  also 

1  History  of  Epidemics  in  Britain,  Cambridge,  1891,  p.  398. 

2  Hist,  dcs  Maladies  Epidcmiques,  Paris,  1817-23,  Tome  I,  p.  260. 

•''  Etudes  sur  les  Maladies  cteintes  et  les  Maladies  nouvelles,  Paris,  1869, 
p.  10. 

*  Ozanam  has  made  a  mistake,  evidently  from  misconstruing  the  Latin  text, 
referring  De  Thou's  remark  to  1510. 


152  THE  RESULTS  OF  THE  RENAISSANCE 

says  that  "coqiieluche"  is  a  name  first  given  to  it  in  1510,  but 
we  have  noted  this  name  in  Feiihieii  a  century  earlier.  It  was  in 
this  latter  year,  according  to  C'reighton,  that  Erasmus  suffered 
from  it.  According  to  the  same  authority,  that  lovely,  wicked, 
puzzling  heroine  of  history,  ]Mary,  Queen  of  Scots,  is  said  to  have 
suffered  from  it  in  15G2. 

Confusion  with  Pertussis.— We  find  in  the  old  Latin  and  French 
works  the  word  cociueluche,  coccolucie,  and  it  is  thus  frequently 
indistinguishable,  as  is  occasionally  the  disease  itself,  from  whoop- 
ing cough,  the  first  intelligible  account  of  which  was  given  by 
Ballonius  in  1578,  though  Sprengel  refers  to  INIezeray  as  mentioning 
the  occurrence  of  whooping  cough  in  1414,  when,  as  we  have  seen 
others  speak  of  an  epidemic  of  influenza,  Sprengel  (III,  <S5)  says 
this  French  name  for  \vhoo])ing  cough  arose  from  the  hood  or 
"cucullio"  with  which  the  sufferers  covered  their  heads  in  France 
in  the  epidemic  of  1510,  or  perhaps  from  coquelicot,  the  name 
of  an  herb,  which  was  at  first  employed  in  the  treatment  of  it.  I 
have  been  thus  prolix  in  the  account  of  the  confusion  as  to  this 
French  term,  and  the  evident  confusion  of  the  diseases,  for  which 
it  stood,  in  order  that  the  lack  of  differentiation  of  two  distinct 
maladies  may  be  seen,  a  little  prior  to  the  time  when  the  separate 
study  of  the  affections  began.  As  a  matter  of  fact,  we  may  plainly 
perceive  that  in  this  instance  we  have  now  no  means  of  knowing, 
with  surety,  what  e])idemics  were  whooping  cough  and  what  were 
influenza,  in  and  before  the  sixteenth  century.  We  may  \enture 
to  apply  the  lesson  thus  learned  to  the  apparent  origin  of  other 
epidemic  diseases,  and  we  recognize  that  new  knowledge  was 
coming  in  to  the  world  to  bless  mankind,  and  not  new  diseases 
to  afflict  it.  Ballonius'  description  unmistakably  identified  whoop- 
ing cough. ^  He  himself  declared  he  had  never  read  an  author 
who  had  given  a  description  of  it.  Notwithstanding  the  assertion 
of  Sprengel  (V,  595)  that  Hoft'mann  first  described  influenza  in 
1709,  under  the  name  of  catarrhal  fever,  it  is  evident  from  the 
following  citation  that  he  was  preceded  by  many  years  by  Willis, 
who,  describing  the  catarrhus  febrilis  of  165S,  says:"  "About 
the  end  of  April  an  affection  suddenly  blazed  forth  which,  as 
though  blown  from  the  stars  by  some  sudden  gust,  all  at  once  fell 
upon  many,  so  that  in  some  towns  in  the  space  of  one  week,  more 
than  a  thousand  men  were  prostrat(>d.  The  pathognomonic  symp- 
tom of  this  disease,  and  that  which  first  attacked  the  })atients. 
was  a  troublesome  cough  with  profuse  expectoration  and  catarrhal 
discharge  from  the  palate,  throat,  and  nares.  There  was  febrile 
disturbance,  which  was  accompanied  by  heat,  thirst,  prostration, 
unaccountable  lassitude,  and  severe  pain  in  the  back  and  limbs." 

'  EpideniioruiH  el  JvphiimTiduin  l^ihri  11.     Piiri.siis,  1040,  p.  2.'57. 

2  Willis:  Opera  Omnia,  Amst.,  1682.     De  Febribus,  Cap.  XVII,  p.  143. 


DIPHTHERIA  153 

"  ]\Iany  of  those  of  weaker  constitution  succumbed,  but  the  strong 
recovered."      He  himself  died  of  it  in  a  later  epidemic   (1075). 

Hoffmann^  speaks  of  it  as  a  quotidian  remittent  fever  epidemic 
in  1709.  Juch-  describes  the  catarrhal  fever  raging  as  an  epidemic 
in  1741  in  many  provinces  of  Germany,  and  Huxham^  says  that 
the  catarrhal  fever  which  spread  through  all  Europe  under  the 
name  of  the  influenza  in  1743  frequently  became  pleuritic  or 
peripneumonic.  John  Fothergill''  speaks  of  an  epidemic  which 
appeared  in  London  in  1775,  and  many  physicians  replied  to  his 
circular  letter  inquiring  into  it,  since  it  prevailed  generally  through- 
out the  British  Isles,  where  it  was  at  that  time  known  as  the 
influenza. 

These  accounts  do  not  by  any  means  include  all  the  records  of 
epidemics  of  influenza  occurring  before  the  nineteenth  century, 
but  are  sufficient  to  prove  its  frequency  and  its  antiquity.  It  is 
hardly  worth  while  to  pursue  the  history  of  it  further,  except  to 
say,  that  it  was  to  some  degree  pandemic  in  Europe  in  1849  and 
then  for  forty  years  little  was  heard  of  it  until  it  suddenly  became 
recrudescent  in  1889-90.  Since  then  repeated  epidemics  have 
occurred  in  all  civilized  countries,  each  milder  than  the  precedent. 
It  mav  now  be  considered  as  mildh'  endemic  and  on  the  verge 
of  becoming  sporadic  again. 

Diphtheria. — Again  it  is  in  the  sixteenth  century  that  the  descrip- 
tion of  an  epidemic  of  diphtheria  is  first  to  be  noted.  It  is  to  be 
found  in  the  works  of  Forestus,^  "Anno  1557,  a  Christo  Servatore 
nostro  nato,  mense  octobre,  gutturi  morbus  epidemicus  adeo 
Alcmariae  grassabatur,  ut  integras  familias  subite  invaderet;  ita 
ut  inter  duos  tresve  septimanas  ex  hoc  malo  in  eadem  urbe  ultra 
ducenti  homines  extincti  sint."*^  Forestus  seemed  to  think  the 
disease  arose  from  a  certain  wind,  which,  with  a  dense,  bad- 
smelling  fog,  had  preceded  it.  Wierus,  a  German  physician, 
described  an  epidemic  occurring  in  1563,  and  Sanne  refers  to  a 
passage  in  Ballonius,  which,  by  the  way,  I  cannot  find,  where  a 
membrane  is  described  as  having  been  found  in  the  trachea  on 

1  Opera  Omnia,  Edit.  1740,  II,  p.  47-48.     (Sprengel.) 

^Juch:  In  Haller's  Disputationes  ad  Morborum  Ilistoriain,  Lausanne, 
1758,  Tomus  V,  p.  297. 

'  An  Essay  on  Fevers,  etc.,  2d  ed.,  London,  1750,  ji.  20. 

*  The  Works  of  John  Fothergill,  Edited  by  Lettsom,  1784,  Vol.  Hi,  p.  251. 

*  L.  C.  Liber  VI,  p.  1 — De  Febribus  pubhce  grassantibus.  According  to 
Chauveau  (Annales  des  Maladies  de  TOrielle,  etc.,  1901,  XXVII,  i)t.  2,  p. 
4.58)  Paracelsus  described  dijihtheria  und(>r  the  name  of  ''prunella'"  before 
either  Forestus  or  Baillou. 

8  This  little  city  of  Alkmar  in  the  Netherlands,  where  IVter  Forest  .saw  and 
described  an  epidemic  of  diphtheria,  and  where  he  himself  contracted  the 
disease,  was  sixteen  years  later  threatened  with  another  calamity.  "If  I  take 
.Alkmar,"  writes  the  Duke  of  Alva  to  King  Philip,  "I  am  resolved  not  to  leave 
a  single  creature  alive;  the  knife  shall  be  i)ut  to  every  throat."  Motley's 
Dutch  Republic,  Vol.  II,  p.  464.  The  bravery  of  the  inhabitants  saved  them 
from  this  merciless  fate. 


154  THE  RESULTS  OF   THE  RENAISSANCE 

autopsy  in  1576.  Ludovicus  ]\Iercatus/  who  died  in  1599,  gives  a 
long  account  of  the  epidemics  in  Spain  in  1583  and  subsequent 
years.  It  was  called  Garrotillo,  after  an  instrument  the  Inquisition 
had  made  them  famiUar  with,  which  was  used  to  strangle  people. 
He  described  the  membranous  condition  of  the  throat  as  "  pustules 
of  various  colors,  especially  verging  toward  the  black,  surrounded 
by  fetid  mucosities,  with  putrefaction  and  softening  of  these 
parts."  A  child  bit  the  father's  finger,  while  he  was  attempting 
to  extract  membrane  from  his  child's  throat,  and  he  died  two 
days  later  of  the  disease,  which  phenomenon  excited  the  wonder 
of  the  author,  who  had  referred  the  causes  to  changes  in  the 
patient's  temperaments,  or  to  atmospheric  conditions.  Thomas 
Bartholinus,-  writing  in  1646,  says  that  the  "Suffocative  angina 
of  children  is  like  an  epidemic  disease,  which  from  the  year  1618 
like  a  pest  attacked  children,  and  infected  and  killed  others  at 
Naples."  "From  the  effects  of  the  comet  of  the  year  1618,  Elisaeus, 
learned  physician  of  this  city,  deduced  the  virulence  of  this  disease." 
Gurlt  (1.  c.)  gives  the  following  extract  from  the  brochure  by 
Andrea  Sgambato,  "De  pestilente  Faucium,"  relative  to  an  epidemic 
of  diphtheria  in  Italy  in  1617,  after  the  appearance  of  three  comets 
in  the  sky:  "The  torches  of  the  comets  were  not  yet  extinguished, 
when  a  pest  began  to  rage  among  the  children  which  at  first, 
especially  in  winter,  spared  no  one.  With  such  celerity  did  the 
infection  pass  from  one  to  the  other,  that  in  a  few  days  a  father 
had  to  mourn  the  loss  of  all  his  children.  It  spared  neither  rich 
nor  poor,  and  ravaged  places  apparently  salubrious  in  the  country 
before  the  city."^  In  the  form  of  a  commentary  on  Aretaeus'  work 
on  the  subject,  INIarcus  Aurelius  Severinus  describes  his  experience 
with  the  pestilential  sore  throat  at  Naples  in  1618.*  Bretonneau 
in  the  additions  to  his  work  (1.  c.)  transcribes  an  extract  from  a 
letter  of  Chisi  (1748?),  concerning  the  disease,  which  is  clearly 
identified  in  the  description  he  gives  of  an  attack  in  his  own  son 
followed  by  diphtheritic  paralysis.  Huxham,  whose  notice  of  the 
disease  in  1775  is  included  in  his  essay  on  fevers  (1.  c),  ascribes 
to  Fothergill,  in  1748,  the  first  accurate  account  of  malignant 
ulcerous  sore  throat  in  England.  Dr.  Francis  Home,  of  Edinburgh, 
in  1765,  published  his  famous  work  on  the  disease  in  the  larynx, 
to  which  he  was  the  first  to  give  in  medical  literature  the  Scotch 
word  of  croup.^    It  was  a  work  which  for  a  long  time  was  widely 

'  Ludovici  Mercati  Opera.,  Francof.,  1620,  V,  p.  134. 

2  Epist.  Med.,  XLIX,  Centur.  1,  Hague,  1740,  p.  205. 

3  Bretonneau;  Des  Inflammations  Speciales  du  Tissu  Muqueux  et  en  Par- 
ticulier— de  la  Diphlherie,  182(),  tran.slates  Carnevale's  de.scrii)tion  of  the 
epidemic  in  Naples  in  1(318,  following  the  comet  (De  Epidemico  Affectu). 
He  also  gives  extracts  from  several  ancient  authors  I  have  not  had  the  oppor- 
tunity, or  have  not  taken  the  space  to  mention. 

••  De  Recondita  Abscessum  Natura,  Frankfort,  1643. 

^  An  Inquiry  into  the  Nature,  Cause  and  Cure  of  Croup,  Edin.,  1765. 


BEGINNING  DIFFERENTIATION  OF  THROAT  AFFECTIONS     155 

quoted,  but  apparently  it  included  many  cases  of  spasmodic 
laryngitis  in  children,  as,  indeed,  continued  to  be  the  case  in  the 
diagnosis  of  diphtheritic  croup,  until  the  advent  of  bacterial 
classification. 

Confusion  with  Scarlet  Fever. — If  the  differential  diagnosis  is 
here  at  fault  in  comparison  with  modern  knowledge,  it  is  still  more 
so  in  many  other  reports,  in  which  it  is  impossible  to  be  sure  that 
scarlet  fever  was  not  included  in  the  category  of  malignant  sore 
throats.  In  very  many  of  the  reports  this  is  self-evident.  Scarlet 
fever,  which  becomes  first  clearly  recognizable  in  the  works  of 
Ingrassias  (1510-1580)  as  rossalia,  and  in  that  of  Ballonius  (1.  c.) 
as  rubeola,  was  first  called  "febris  scarlatina"  bv  Svdenham. 
It  has  often  appeared  as  an  epidemic  when  diphtheria  has  also 
been  prevalent.  This  confusion  is  noted  in  the  early  work  of 
Fothergill,^  who  first  noted  these  throat  disorders  in  England  in 
1739,  and  the  same  criticism  may  be  applied  to  the  work  of  Huxham. 
This  is  still  more  apparent  in  the  early  American  accounts  of  throat 
epidemics.  Dr.  William  Douglas  communicated  to  a  medical 
society  in  Boston  his  observations,  which  had  a  title,  "  The  Practical 
History  of  a  New  Epidemical  ^Miliary  Fever  with  an  Angina 
Ulcusculosa,"-  which  raged  in  Boston,  but  first  broke  out  in  King- 
ston township,  fifty  miles  eastward  of  Boston,  on  the  20th  of  May, 
1735.  Dr.  Douglas,  however,  as  may  be  judged  from  the  title, 
did  not  recognize  it  as  the  disease  described  by  Forestus.  Dr. 
Cadwallader  Golden,  in  1735,  is  said  also  to  have  published  a 
treatise  on  "The  Sore  Throat  Distemper,"  and  it  is  to  him  that 
Samuel  Bard,  M.D.,  in  1771,  dedicated  his  essay,  "An  Enquiry 
into  the  Nature,  Cause,  and  Cure  of  the  Angina  Suffocativa  or 
Sore  Throat  Distemper, "'^  a  work  so  highly  esteemed  by  Bretonneau 
that  he  translated  it  into  French.  Dr.  Jonathan  Dickinson,  the 
first  president  of  Princeton  College,  also  described  the  epidemic 
of  1734-1735  in  a  letter  from  Elizabethtown,  N.  J.,  to  a  friend, 
which  was  afterward  printed  as  a  tractate  in  1740,  "Observations 
on  That  Terrible  Disease,  Vulgarly  Called  the  'Throat  Distemper.'  " 
Angina  was  epidemic  many  times  in  New  England  from  1733  to 
1787,  and,  without  a  doubt,  this  was  probably  both  scarlatinal 
and  diphtheritic  according  to  our  present  nosology. 

Beginning  Differentiation  of  Throat  Affections.  —  Perhaps  no 
better  example  of  this  undifferentiated  state  of  acute  throat  inflam- 
mation can  be  found,  after  the  decline  of  the  Ilipj)ocratic  pathology 
and  the  classification  of  Aretaeus,  than  in  the  works  of  Christian 
Gottlieb  Ludwig,^  whose  namesake,  eighty  years  later,  gave  the 

1  The  Works  of  John  Fothergill.  ...  By  J.  C.  Lettsom,  London,  1783, 
I,  p.  365. 

^  Vid. :  An  Essay  on  Scarlet  Fever.    By  Caspar  Morris,  Phil.,  1853.   Appendix. 

^  A  very  rare  book,  I  believe,  but  to  be  found  in  the  library  of  the  New 
York  Academy  of  INIedicine. 

■*  Institutiones  Medicinae  Clinicae,  Lipsiae,  1758,  p.  134. 


156  THE  RESULTS  OF   THE  RENAISSANCE 

patronymic  to  a  well-marked  septic  condition  of  the  pharynx.  In 
the  eifihteentli  centnry  Lndwig  drew  a  sort  of  com})osite  ])icture, 
which  in  a  few  years  was  to  beo;in  to  undergo  a  process  of  resolution 
into  its  component  j)arts.  Xevertheless  modern  differentiation 
of  throat  affections  may  be  said  to  have  begun  at  this  time.  Rush' 
and  Chalmers-  evidently  confounded  spasmodic  and  dij)htheritic 
laryngitis,  but  Rush  later,  in  his  works,  recognized  them  as  two 
different  diseases.  John  ^liller,  to  whom  Rush  addressed  a  letter 
on  the  subject,  described  "pseudocrouj)'"  and  wrote  on  the  asthma 
and  whooping  cough  in  1768-69.  Wichmaim,''  in  1794,  still  further 
developed  the  differential  diagnosis,  Michaelis  having,  in  Germany, 
exhaustively  described  true  croup  in  177.S. 

Tracheotomy. — An  account  of  the  history  of  tracheotomy  natu- 
rally follows  that  of  diphtheria.  Since  the  days  of  Paulus  Aegineta, 
who  himself  simply  quoted  from  an  earlier  author,  the  opening 
of  the  air  tube  was  described  by  the  majority  of  systematic  medical 
writers,  but  apparently  ])ractised  by  none  whose  records  have 
reached  us  until  the  time  of  Brasavola.  Numerous  Arabian  and 
pre-Renaissance  writers  mention  it.  Lisfranc,  Nicholas  Florentinus, 
William  of  Salicet,  Petrus  d'Abano,  all  make  reference  to  it.  Some 
have  ascribed  to  Beniveni,  who  died  in  1502,  the  first  actual  opera- 
tion, but  a  reference  to  the  1507  edition  of  his  book*  discloses  the 
fact  that  his  operation  was  an  external  })haryngeal  incision  into 
a  perij)haryngeal  or  perilaryngeal  abscess,  and  by  no  means  a 
tracheotomy,  though  it  was  successfully  done  for  the  purpose  of 
relieving  dyspn(ra.  It  is  doubtful  whether  Guido-Guidi  ever  jjer- 
formed  the  operation,  though  he  recommends  and  describes  that 
of  Antyllus  as  a  desperate  resort,  and  he  describes  and  figures 
silver  and  gold  tracheotomy  tubes.-"  He  was  a  friend  of  Cellini, 
and  died  in  1569.  Casserius  ascribes  to  Brasavola,  who  died  in 
1555,  several  operations  for  tracheotomy,  the  first  operation 
being,  according  to  Sanne,  in  1546.  Brasavola  is  quoted  as  saying: 
"When  there  is  no  other  possibility,  in  angina,  of  admitting  air 
to  the  heart,  we  must  incise  the  larynx  below  the  abscess,"  etc. 
(Holmes.) 

Casserius  practised  the  operation  which  his  master,  Fabricius, 
described  and  defended.  Casserius'  work''  is  a  very  fine  disserta- 
tion on  the  anatomy  of  the  larynx  and  the  ear,  but  his  description 
of  the  operation  of  tracheotomy  which  he  himself  ])erformed  is 
not  equal  to  that  of  Fabricius,  who  never  did  the  operation. 

'  Medical  Inquiries  and  ()b.s('rvation.s.     London,  1789,  p.  118. 

=  An  Account  of  the  Weather  and  Disea.ses  of  South  Carohna,  London,  177G. 

^  Ideen  zur  Diagnostik.     Hannover,  1794-1802. 

••  Dc  Abditis  Noniiullis  ac  Mirandis  Morborum  et  Sanationimi  Causis, 
Flor.,  1.507,  Obs.  XXX\  IIL 

s  De  Curatione  Membratim  Vidi  Vidii  Junioris.  Liber  VIII,  Cap.  .5,  Flor., 
1594,  p.  324. 

^  De  Vocis,  Auditusque  Organo,  Historia  Anatomica,  1600. 


THE  OPERATION  OF  FABRIC  I  US  157 

Giirlt^  seems  to  understand  that  Casserius  incised  the  tracheal 
rings,  but  I  do  not  understand  that  the  "divisis  annuHs"  is  to 
be  so  construed,  but  rather  that  they  were  separated,  as  in  the 
operation  of  AntyUus.  This  is  borne  out  by  the  description  of 
Fabricius  and  by  the  subsequent  history  of  the  operation.  It  is 
probable  that  the  difficulty  in  differential  diagnosis,  as  to  the  site 
of  the  obstruction  in  respiration,  at  a  period  before  they  knew  any- 
thing either  of  laryngoscopy  or  of  the  physical  diagnosis  of  pulmo- 
nary conditions,  and  perhaps  the  lingering  criticism  of  Aretaeus, 
that  it  was  the  "pneuma"  itself  or  the  vital  principle  which  was 
affected  in  these  cases,  caused  physicians  to  falter  in  what,  to  us, 
seems  the  most  pressing  of  indications  for  operative  interference. 
The  dangers  of  the  operation  were  also  grossly  exaggerated.  So 
well  did  Casserius  appreciate  these  fallacies  that  he  declared  that 
those  who  rejected  bronchotomy  are  "  inhuman,  awkward,  timorous, 
and  are  even,  as  it  were,  to  be  held  as  homicides."  Casserius' 
work  was  published  1600  and  that  of  his  master,  in  which  I  have 
found  the  reference  to  tracheotomy,  in  1617.  Apparently,  there- 
fore, he  preceded  him  in  the  boldness  with  which  he  ad\-ocated  the 
operation.  Certainly  he  surpassed  him  in  having  himself  per- 
formed the  operation.  Since,  in  Fabricius'  long  dissertation  on 
the  subject,  he  does  not  allude  to  Casserius,  who  was  his  favorite 
pupil  and  his  successor,  we  may  conjecture  that  the  former's 
chapter  on  the  subject  must  have  been  written,  at  least  before 
Casserius  published  his  liook. 

The  Operation  of  Fabricius. — It  is  thus  that  Fabricius  ab  Acqua- 
pendente,  in  florid  Latin,  eloquently  praises  the  operation  of 
opening  the  aspera  arteria:-  "Of  all  the  surgical  operations,  which 
are  performed  on  man  for  the  ])reser\ation  of  his  life  by  the  physi- 
cian, I  have  always  judged  to  be  the  foremost  that  by  which  man 
is  recalled  from  a  quick  death  to  a  sudden  repossession  of  life,  a 
feat  which  raises  the  surgeon  nearest  to  the  level  of  Aesculapius; 
that  operation  is  the  opening  of  the  aspera  arteria,  by  which 
patients,  from  a  condition  of  almost  suffocating  obstruction  to 
respiration,  suddenly  regain  consciousness,  and  draw  again  into 
their  heart  and  lungs  that  vital  ether,  the  air,  so  necessary  to  life, 
and  again  resume  an  existence  which  had  been  all  but  anniliilated." 
Fabricius  reviews  the  disputes  of  former  authors  as  to  its  utility, 
and  says  that  it  is  useless  when  the  lungs  are  affected  and  the  whole 
trachea  is  full  of  material.  "  It  is  justifiable,  in  short,  when  the 
obstructing  matter  is  only  in  the  larynx  above  the  place  of  incision. 
When  below,  it  is  to  be  refrained  from."  He  assures  us,  contradict- 
ing himself  somewhat,  that  even  when  there  are  some  signs  that 
the  trachea  is  full,  we  should  still  operate.    To  escape  the  criticism 

^  Geschichtc  dcr  Chirurgio,  II,  487. 

-  Opera   Chirurgica,  De  C'hirurgicis  operationibus,    Cap.  44,  Ludg.  Batav., 
1723,  p.  475 


158  THE  RESULTS  OF  THE  RENAISSANCE 

of  perhaps  hastening  death,  "and  because  from  the  operation  no 
small  emolument  may  be  derived,"  he  advises  that  the  patient's 
friends  should  be  told  of  the  desperate  nature  of  the  case.  The 
operator  should  be  a  good  anatomist.  The  fauces  should  be  first 
explored  with  the  finger,  alone  or  armed  with  a  short  knife,  bound 
to  it  in  order  to  rupture  any  abscess  which  may  be  present,  but  if 
the  trouble  is  in  the  larynx  this  is  of  little  use.  He  is  the  first  (unless 
it  is  Casserius)  to  criticise  the  transverse  skin  incision  of  the  ancients, 
and  counselled  that  it  should  be  made  vertically  over  the  third 
and  fourth  tracheal  cartilage.  He  defends  the  operation  against 
the  criticism  of  Aretaeus  w4th  quite  modern  arguments.  As  for 
the  cartilage  not  healing  by  primary  intention,  would  it  not  heal 
by  secondary?^  But  even  if  it  should  not  heal,  the  soft  parts  would 
sufficiently  cover  it.  A  longitudinal  mark  with  ink  was  to  be  made 
down  the  middle  line  of  the  neck  and  a  cross  mark  at  the  point  of 
tracheal  incision — scarcely  the  breadth  of  a  thumb  below  the 
lower  border  of  the  larynx.  Fabricius  describes  the  cannula  more 
explicitly  than  Guido.  Straight  and  curved  cannulas  were  in  use, 
but  Frabricius  preferred  the  former.  He  declares  that  the  surgeons 
of  his  own  time,  frightened  by  the  warnings  of  the  ancients,  have 
not  performed  the  operation,  nor  has  he  himself  done  so.  Not- 
withstanding this  work  of  Fabricius,  which  seems  first  to  have  been 
published  in  1617,  though  presumabh''  written  several  years  earlier, 
it  cannot  be  doubted  that  the  operation  was  more  common  than  we 
should  infer  from  his  remark,  for  Ballonius-  in  1574,  in  considering 
the  advisability  of  the  operation,  said :  "  Of  course  it  is  dangerous, 
but  if  it  is  done  by  a  skilful  hand,  which  knows  how  to  avoid  the 
recurrent  nerves,  it  is  free  from  danger.  It  promises  certain  safety. 
At  anv  rate  it  is  better  to  trv  a  doubtful  remedv  than  none,  and 
it  may  be  that  it  is  omitted  to  the  great  detriment  of  patients." 
It  is  probable,  therefore,  that  Fabricius'  work  on  the  subject  had 
been  written  before  that  of  Casserius,  and  it  is  evident  that  the 
operation  had  been  growing  in  favor  in  the  fifty  years  which  had 
elapsed  since  the  time  of  Brasavola,  and  had  probably  been  often 
performed  in  that  time.  jMarcellus  Donatus  in  his  curious  book,'^ 
first  published  in  1586,  strongly  urged  tracheotomy  when  indicated, 
and  in  spite  of  the  little  esteem  which  his  work  has  met  with  at 
the  hands  of  the  historians,  he  was  one  of  the  first  to  urge 
the  pressing  importance  of  postmortem  examinations.  Habicot,'* 
who  was  something  of  a  charlatan,  ])ublished  a  tractate  entitled: 
"Question  chirurgicale,  dans  laquelle  il  est  demontre  que  le  chirur- 

^  The  cartilage  is  alway.s  spoken  of,  but  of  course  it  is  the  tissue  between  the 
rings  which  is  referred  to. 

2  Opera  Omnia,  Venetiis,  1734,  Tom.  I,  p.  1G:3.  Epidemorum  et  Ephemeri- 
dum,  Lib.  II. 

2  De  ilistoria  Medica  Mirab.,  Lib.  Ill,  Cap.  I,  Francof.,  1613,  p.  230. 

^  See  extract  from  his  work  cited  in  Diet.  Hist,  de  la  M^decine,  (Dezeimeris) 
II,  Paris,  1834,  p.  082. 


LARYNGOCENTESIS  159 

geon  doit  absolument  pratiqiier  I'operation  de  la  bronchotomie, 
autrement  la  perforation  de  la  flute  on  tuyaii  dii  poulmon"  (1620). 

His  experience  consisted  principally  in  two  operations  on  persons 
not  affected  with  angina,  one  a  wound  of  the  larynx  and  another 
a  case  of  foreign  bodies — gold  pieces — in  the  pharynx.  He 
describes  the  size  and  forms  of  tracheal  cannulse.  Louis,  who  has 
given  a  most  excellent  history  of  the  operation/  quotes  from 
Fonseca,  a  Portuguese  author  who  died  in  1032,  the  curious  history 
of  a  young  surgeon  of  London  who  was  bribed  to  attempt  to  save 
the  life  of  a  robber  who  was  to  be  hung.  He  made  an  incision 
into  the  trachea  and  inserted  a  tube.  The  noose  failed  thus  to 
shut  oft'  the  malefactor's  breath,  but,  being  a  heavy  man,  although 
life  was  not  extinct  when  the  body  was  delivered  to  his  friends,  he 
died,  very  shortly  after  regaining  consciousness,  from  the  effect 
of  his  great  weight  producing  other  fatal  damage. 

Sennert,^  a  voluminous  writer  in  the  early  part  of  the  seventeeth 
century,  who,  on  a  careful  inquiry  into  the  efficacy  of  birds'  nests 
in  angina,  came  to  the  conclusion  it  was  due  to  birds'  dung  mixed 
with  the  dirt,  approved  of  tracheotomy  in  desperate  cases,  if  per- 
formed by  skilful  hands.  Li  1646  the  question  of  tracheotomy 
was  discussed  in  the  letters  of  Thomas  Bartholinus  and  Moreau.^ 
The  latter  says,  writing  from  Paris:  "As  for  me,  I  have  seen 
innumerable  people,  suffering  with  angina,  saved  by  venesection 
alone  from  the  arms,  so  often  praised,  fewer  carried  off"  by  the 
neglect  of  the  administration  of  remedies  at  the  proper  time,  and 
a  very  few  in  whom  bronchotomy  might  have  been  judiciously  and 
seasonably  used."  He  describes  the  operation  he  performed  on  a 
soldier,  in  which  he  made  use  of  the  transverse  incision,  and  used 
a  curved  leaden  tube  with  strings  to  attach  it  around  the  neck. 
He  had  performed  it  also  in  children,  and  one  should  not  wait 
until  they  are  nearly  suffocated,  he  says.  Li  them  a  shorter  tube 
is  to  be  used. 

Laryngocentesis. — In  another  work  of  Bartholinus^  he  mentions 
that  John  Van  Home,  in  dissecting  the  body  of  a  man  dead  of 
phthisis,  pointed  out,  among  other  operations,  the  place  for  a 
laryngotom3\  Although  Sprengel  asserts  (\H,  144)  that  Frederic 
Dekkers  was  the  first  to  recommend  paracentesis  of  the  trachea, 
in  a  work  published  in  1694,  on  bronchotomy,  Sanne  states  that, 
according  to  ]\Ialavicini,  Sanctorius  (died  1636)  first  made  use  of 
a  trocar,  the  cannula  of  which  he  left  in  the  wound  for  three  davs. 
This  procedure,  laryngocentesis,  was   also  described   in   1748  by 

^  Sur  la  Bronchotomie.  M6moires  de  I'Academie  Roj'ale  de  Chirurgie,  Paris, 
1784.    T.  IV,  p.  455. 

2  Opera  Omnia,  Tom.  II,  Lib.  II,  Part  I,  Cap.  24,  Parisiis,  1641,  p.  400. 

■^  Tliomae  Bartholini  Epistolae  Med.  Centur.,  1740,  I  Epist.,  LXXX  and 
LXXXI,  p.  831. 

^  Acta  Medica  and  Phil.  Hafn.,  Hafniae,  1673,  I. 


160  LARYNGOrOMY 

Garengeot.^  For  the  reasons  suggested,  or  perhaps  for  others  less 
apparent,  tracheotomy  found  its  way  into  favor  very  slowly. 
The  singular  mistake  of  Detharding,'  in  the  early  part  of  the 
eighteenth  century,  although  it  doubtless  caused  many  useless 
operations,  must  have  done  much  to  familiarize  the  profession  and 
the  laity  with  the  operation.  His  advocacy  of  tracheotomy  in 
cases  of  drowning,  advanced  in  1714,  arose  from  the  observation 
that  the  lungs  and  the  stomach  of  a  drowned  person  did  not  contain 
the  water,  which  had  formerly  been  supposed  to  be  the  cause  of 
their  death.  As  one  of  his  arguments  he  cites  Wepfer,  from  whom 
we  have  had  occasion  to  cjuote,  as  having  incised  the  trachea  of 
a  beaver  after  having  been  held  under  the  water  until  drowned, 
and  as  having  been  unable  to  press  any  water  out  of  the  lungs. 
He  supposed  that  the  structure  and  action  of  the  glottis  and 
epiglottis  prevented,  not  only  the  entrance  of  the  water,  but 
frustrated  the  subsequent  efforts  at  artificial  respiration.  He 
counselled,  therefore,  doing  a  tracheotomy  and  blowing  air  into 
the  lungs.  While  this  idea  was  frequently  put  into  practice  by 
many  eminent  surgeons  for  more  than  a  hundred  years,  it  never 
was  universally  accepted  as  a  proper  procedure,  and  it  finally  fell 
into  disuse. 

The  Modern  Operation. — ^We  now  note  the  first  great  advance 
in  the  technique,  since  the  first  mention  of  the  operation.  Although 
others,  as  Casserius  and  Fabricius,  had  declared  that  cut  cartilages 
healed  kindly  and  easily,  division  of  them  was  always  avoided. 
Juncker,^  in  1721,  said  of  bronchotomy,  that  some  advised  the 
ring  to  be  cut,  which  allowed  more  convenient  placing  of  the  tube, 
but  he  thought  this  renders  the  healing  more  difficult,  and  he  advised 
that  it  should  only  be  done  for  foreign  bodies,  in  which  case  many 
rings  may  be  cut.  A  little  before  this  time,  Heister^  apparently 
first  advised  the  division  of  the  rings  as  a  routine  practice.  He 
sjjeaks  of  tracheotomy  in  the  "Briiune,"  and  for  resuscitation  of 
the  drowned.  Flatner,^  in  1758,  approved  of  bronchotomy,  when 
necessary,  in  angina,  and  says  it  is  safe  to  cut  the  cartilaginous 
rings.  He  did  not  approve  of  paracentesis.  Vic  d'Azyr,*^  in  1776, 
communicated  to  the  Royal  Society  of  IMedicine  of  Paris  his 
reflections  on  the  possibility  of  laryngotomy  between  the  thyroid 
and  cricoid  cartilages. 

Laryngotomy. — According  to  Sprengel,  Desault  was  the  first 
who   i)ractiscd  laryngotomy,  splitting  up  the  thyroid  cartilage  in 

iTraite  des  Operations,  etc.,  2d  Edit.,  Paris,  1731.  Perhaps  also  in  the  1st 
Edit.,  1720. 

-  P^pistola  ad  Luc.  Schrockium.  Haller's  Disputationes  Chirurgicae,  Lausanne, 

1755,  T.  II,  p.  42S. 


ibb,   1.  11,  p.  ^zis. 

^  Conspectus  Chirurgiae,  Halae,  1721,  p.  665. 
^  Chirurgie,  Niirnberg,  1719,  p.  555. 

5  Institutiones  Chirurgiae,  Lipsiae,  1758,  p.  65. 

6  Hist,  de  la  Soc.  Koyalo  de  Med.,  1776,  p.  311. 


OPERATIONS  FOR  NASAL  POLYPI  161 

an  individual  in  the  larynx  of  whom  a  foreign  body  had  lodged. 
While  Desault  urged  the  propriety  of  such  a  procedure  in  cases  of 
this  kind,  I  find  no  record  of  the  fact  that  he  performed  it,  in  any 
of  the  many  editions  the  great  Bichat  issued  of  his  works.  We 
have  noted  a  similar  suggestion  in  Juncker,  in  regard  to  the  tracheal 
rings.  Pelletan^  records  a  case,  operated  on  in  17SS,  in  which  he 
did  a  laryngotomy,  dividing  the  thyroid  cartilage  in  order  to  push 
down  into  the  oesophagus  a  foreign  body  arrested  at  that  point. 
The  man  recovered  but  remained  hoarse,  and  according  to  Pelletan 
such  will  always  be  the  case  when  the  incision  includes  the  larynx. 
In  another  case  (Obs.  IV),  in  ISOo,  he  flivided  the  cricoid  cartilage 
alone.  Holmes  attributes  the  origin  of  the  modern  tracheotomy 
tube  to  A.  G.  Richter,  who  published  his  Obs.  Chirurg.  in  1776.^ 

Tracheotomy  in  Diphtheria. — From  what  has  preceded  it  is  evident, 
I  think,  that  man\'  of  the  cases  in  which  tracheotomv  had  been 
done,  were  suffering  from  diphtheria;  but  when  Bretonneau  wrote 
his  great  treatise"'  he  cited  from  Borsieri  the  report  of  an  operation, 
as  the  first  instance  in  which  it  was  clearly  evident  that  the  obstruc- 
tion to  breathing,  for  which  it  was  done,  was  due  to  croupous 
laryngitis.  It  was  performed  by  Andree,  a  skilful  London  surgeon, 
in  1782,  u])on  a  five-year-old  boy,  who  recovered  in  fifteen  days.'' 

INTRANASAL  SURGERY  AND  PATHOLOGY  OF  THE 
SEVENTEENTH  AND  EIGHTEENTH  CENTURIES 

Operations  for  Nasal  Polypi. — We  will  now  turn  our  attention 
to  that  part  of  intranasal  surgery  which  has  always  occupied, 
to  some  extent,  the  activities  of  medical  men — the  removal  of 
nasal  polypi.  We  have  seen  the  skilful  procedures  of  Hippocrates. 
We  have  seen  the  barbarous  modifications  of  them  by  Paulus  and 
the  Arabians  with  their  knotted  strings  and  little  saws.  \'elpeau,^ 
who  gives  a  verv  much  fuller  account  of  the  ancient  historv  of 
this  subject  than  I  can  find  room  for  here,  refers  to  a  procedure  I 
have  not  elsewhere  met  with  in  mx  reading.  He  savs  that  William 
of  Salicet  proposed  the  gradual  dilatation  of  the  anterior  openings 
of  the  nostrils  with  a  sponge,  or  some  other  device,  to  render 
avulsion  of  nasal  polypi  easier  of  execution.  The  knotted  strings 
of  horse-hair  and  of  silk  were  soon  abandoned  after  the  Benaissance, 
and  in  1571  Aranzi  or  Arantius,  in  giving  an  account  of  his  method 
of  dealing  with  nasal  polypi,  describes  not  only  a  forceps  with 

1  Clinique  Chirurgicalo,  Paris,  ISIO,  I,  p.  1,  Obs.  7. 
-  Observationum  chirurgicarum  fasciculus  secundus.     Gottingae,  1776. 
^  Dcs  Inflammations  speciales  ...     et  ...     do  la  dijihtherite,  Paris, 
1826,  p.  327 

*  The  reader  is  referred  to  the  treatise  of  Sanne  on  Diphtheria,  to  Gurlt's 
History  of  Surgery,  and  to  Louis  Sur  la  Bronchotomie  (1.  c.)  for  a  fuller 
account  of  the  operation. 

*  Nouveaux  Elements  de  Mcdecine  Operat.,  Paris,  1S;39,  III,  p.  59o. 

11 


162  INTRANASAL  SURGERY  AND  PATHOLOGY 

long  jaws  he  had  invented  for  the  purpose,  but  he  gives  still  more 
interesting  details  of  his  way  of  illuminating  the  anterior  nares.^ 
He  speaks  of  the  difficulty  of  blood  obstructing  the  view  in  the 
use  of  the  knife,  and  to  obviate  this  he  constructed  his  long  forceps. 
He  obtained  illumination  by  placing  the  patient  in  a  darkened 
room  and  making  a  hole  through  a  wooden  shutter  to  admit  the 
ray  of  light,  which  was  to  fall  directly  into  the  nasal  cavity,  which 
he  rendered  more  patent  by  raising  the  end  of  the  nose.  On  cloudy 
days  he  used  artificial  light,  magnified  by  a  water  bottle. 

Remembering  that  in  the  sixteenth  century  not  only  were  the 
Greek  medical  works  more  faithfully  translated  into  Latin,  but 
that  they  were  more  widely  read  in  the  original,  we  may  easily 
conjecture  that  Fallopius'^  drew  his  idea  of  the  wire  snare  for  nasal 
polypi  from  the  works  of  Hippocrates,  but  it  differed  very  much 
from  the  devices  the  latter  employed,  and  it  is  in  very  fact  the 
modern  nasal  snare  of  Jarvis,  without  the  wheel,  of  which  all 
others  at  present  in  use  are  modifications.  By  Fallopius'  reference 
to  nasal  hemorrhoids  we  also  perceive  he  was  familiar  with  the 
Arabian  pathology,  but  he  makes  a  distinction  between  them  and 
ordinary  polypi,  practically  much  as  we  now  do  more  exactly. 
The  hemorrhoids  were  our  vascular  hypertrophies,  and  the  polypi 
were  our  oedematous  growths,  the  former  being  noted  far  back  in 
the  nose  (posterior  parts  of  the  inferior  turbinated  bones?),  and 
the  latter  being  situated  in  more  accessible  regions,  as  a  rule. 
For  the  cure  of  the  anterior  growths  he  used  the  ligature,  lea^'ing 
it  around  the  growth  for  two  or  three  days,  when  it  would  fall  off 
with  the  constricted  mass.  This  method  he  did  not  apply  to  hemor- 
rhoids or  "carunculffi"  in  the  back  part  of  the  nose.  He  says: 
"But  when  the  polypus  is  well  within  the  nose  it  is  difficult  to  use 
the  ligature,  which  should  encircle  the  roots  of  the  polyp."  He 
mentions  the  forceps  operation  of  Paulus  and  continues:  "But 
I  take  a  silver  tube  which  is  neither  too  broad  nor  too  narrow, 
and  then  a  brass  or  steel  wire,  sufficiently  thick,  preferably  the 
iron  wire  from  which  harpsichords  are  made.  This  doubled,  I 
place  in  the  tube  so  that  from  this  wire  a  loop  is  made  at  one  end 
of  the  tube,  by  which,  used  in  the  nares,  I  remove  the  polyp. 
When  the  polyp  is  engaged  in  the  loop,  I  push  the  tube  to  the  root 
of  the  polyp,  and  then  pull  on  the  metal  threads  sticking  out  at 
the  lower  part  of  the  tube,  and  thus  I  constrict  the  roots  of  the 
polyp  and  extract  it,  since  by  this  wire  loop  the  root  of  the  polyp 
is  cut  because  it  is  a  soft  substance."  Harder  growths  he  pulled 
dow^n  so  that  he  could  cut  oft'  the  roots  with  a  knife. 

^  Julii  Caesaris  Arantii:  Dc  Tumoribus  Secundum  Locos  Affoctos,  p.  172. 

2  Institutiones  Anatomicae:  De  Tumoribus  Narium,  in  Opera  Omnia., 
Francofurt,  1600,  II,  p.  298. 

Fallopius'  tractate,  De  Tumoribus  praeter  Naturam,  was  first  published 
1573,  and  the  publication  of  his  snare  dates  back  to  that,  but  he  died  in  1562. 


OPERATIONS  FOR  NASAL  POLYPI 


163 


Fallopius  praised  his  instrument  as  very  efficacious,  and  he  used 
it  also  for  polypi  of  the  rectum.  He  condemns  strongly  the  use 
of  a  cautery  through  a  speculum,  regarding  the  practice  as  danger- 
ous. He  also  speaks  of  the  string-sawing  method,  which  he  had 
never  used.  His  is  the  first  improvement  on  the  method  of 
Hippocrates  in  removing  nasal  polypi.      Fallopius  died  in  1562,  two 

Fig.  12 


Fallopius'  nasal  snare. 

years  before  his  much-admired  preceptor,  Vesalius.  The  descrip- 
tion of  his  snare  was  not  published  for  many  years  after  his  death. 
Rhinologists  cannot  fail  to  be  struck  with  the  appearance,  at  such 
an  early  date,  of  what  is  practically  a  modern  instrument.  For 
some  reason  the  advantages  of  the  steel  wire  were  not  appreciated, 
and  the  instrument  was  not  destined  to  come  into  use  until  it  had 
been  reinvented  after  the  development  of  other  adjuvants  of  intra- 
nasal  surgery.     Kubo^  in  an   interesting  article  on  the   ancient 

Fig.  13 


Fabricius'  forceps  for  nasal  polypi. 


history  of  rhinology  in  Japan  refers  to  a  snare,  similar  to  if  not 
identical  with  that  of  Fallopius,  which  he  supposes,  probably  with 
reason,  to  have  been  invented  inde])endently.  jNIany  snares  and 
devices  for  tying  ligatures  around  pohpi  were  subsequently  in\ented, 
but  without  the  elastic  steel  wire  they  were  little,  if  any,  superior  to 
the  intranasal  forceps.     These  latter,  though  used  by  Aranzi  and 

1  Archiv  fiir  Lar3'ngologic  und  llhinologie,  XIX,  p.  145,  1907. 


104  IXTRAXASAL  SURGERY  AXD  PATHOLOCY 

even  by  earlier  operators,  came  into  favor  principally  through  the 
advocacy  of  Fabricius  ab  Acquapendente.  Gurlt  speaks  of  Dale- 
champs,  a  French  surgeon  of  about  the  same  jieriod,  using  an 
instrument  similar  to  Aranzi's,  l)ut  Pare  knew  no  better  treatment 
for  polypi  than  local  aj)i)lications  and  the  cautery.  The  forceps 
invented  by  Fabricius  were  really  scissors  curved  at  the  end.  There 
were  many  modifications  of  them.  Thus,  John  \'an  Ilorne  (1G21- 
1770)  added  teeth  to  their  points  with  which  to  seize  the  polyp. 

Thomas  Bartholinus  relates  a  fatal  case  of  hemorrhage  from 
their  use,  although  Fabricius  had  boasted  they  were  entirely  safe 
(tutissimum). 

Riolan^  (1577-1057),  in  his  works,  illustrates  the  general  practice 
in  regard  to  intranasal  surgery  of  this  kind,  which  we  may  see  was 
inferior  to  either  the  procedure  of  Fallopius  or  to  that  of  Fabricius 
for  the  removal  of  polypi.  He  mentions  five  methods:  (1)  Astrin- 
gent and  other  local  ai)plications  of  drugs.  (2)  The  operation  of 
Celsus  and  Galen — cutting  with  a  flat-pointed  probe  and  burning 
the  roots  with  a  cautery.  (8)  When  coming  down  behind  the 
palate,  pull  it  down  with  the  forceps  and  cut  it  off.  (4)  It  may  be 
burned;  or  (5)  cut  of^' with  horse-hair  in  the  manner  recommended 
l)y  Mesua. 

Glandorp,  in  whose  tractate'  published  in  1028  full  references 
will  be  found  to  previous  literature,  apparently  was  ignorant  of 
Fallopius'  instrument,  for  his  own  device  was  greatly  inferior  to 
it,  though  it,  unlike  the  earlier  and  better  snare,  was  adopted  and 
modified  by  many  subsecjuent  operators.  It  was  a  sort  of  a  hook, 
a  shank  with  a  curved  end  and  an  eye  at  the  point,  through  which 
a  waxed-silk  thread  was  to  be  passed.  A  knot  being  firmly  tied 
and  the  thread  twisted,  the  ])oI\p  was  thus  ligated  until  upon  the 
ninth  day  it  would  fall  away.  Fa})ricius  Ilildanus  used  a  seton  in 
the  nose,  and  tried  to  get  rid  of  the  i)olyp  by  su])puration.  More 
than  200  years  after  Fallopius'  death,  Levret  ])ublished,  in  1771,^ 
a  most  elaborate  and  exhaustive  treatise,  containing  accounts  of 
the  most  ingenious  and  complicated  instruments  for  the  ligation 
and  extraction  of  polypi.  Notwithstanding  their  ingenuity,  they 
seem  utterly  worthless  viewed  from  a  modern  standpoint. 

Much  more  practical  and  efhcient,  it  would  seem  to  us,  were 
the  instruments  of  Benjamin  Bell.''  Although  Ileymann  asserts 
that  the  first  mention  of  Belloc's  sound  is  to  be  noted  in  the  work 
of  Deschamps  in  1805,  a  similar  instrument  is  to  be  found  described 
in  Bell's  work  in  1791.  He  figures  different  forms  of  snares  and 
forceps  for  removing  nasal  polypi.     The  best  of  the  former  is 

'  Opera  Omnia,  Parisiis,  1(510,  Morbi  Narium,  ]).  41S;  (>t  .seq. 

^  Tractatus  da  polypo  narium,  etc. 

'  Observation  sur  la  cure  radicalo  de  plusieurs  polypes  de  la  Matrice,  de  la 
Gorge,  et  du  Ncz.,  3  ed.,  Paris,  1771. 

*  System  of  Surgery  (first  edit.,  1784),  Am.  edit.,  Worcester  and  Boston,  1791, 
vol.  Ill,  p.  42  et  seq. 


THE  PATHOGENESIS  OF  NASAL  POLYPI  165 

perhaps  a  double  cannula,  in  each  tube  of  which  the  end  of  a  pli- 
able wire  was  to  be  inserted  and  drawn  through,  leaving  a  loop  at 
the  end.  The  double  cannula  was  then,  after  adjustment  to  the 
polyp,  revolved  in  the  nose,  which,  twisting  the  wire,  constricted 
the  polyp.  The  apparatus  was  then  left  in  the  nose,  tightened  at 
intervals,  until  after  a  few  days  the  growth  came  away.  Some  of 
the  operations  performed  with  forceps  were  of  the  most  atrocious 
nature.  For  the  details  of  a  revolting  operation  for  polypus  nasi 
I  commend  the  reader  to  descriptions  in  Le  Drans'  works. ^  After 
failure  of  evulsive  methods,  he  used  a  seton  saturated  with  some 
medicament  of  a  styptic  nature. 

Percival  Pott,'-  who  mentions  the  wire  snare,  declares  lie  has 
seen  the  septum  and  pieces  of  the  palate  pulled  away  by  the  forceps 
and  other  evulsive  methods.  He  believed  there  were  many  polypi, 
which,  though  not  malignant,  should  be  left  alone  on  account  of 
the  impossibility  of  a  successful  operation.  He  denied  with 
scorn  the  efficacy  of  escharotics  and  setons.  ^lann,  according  to 
Cloquet^  and  Petit,  according  to  Garengeot,^  first  split  the  soft 
palate  for  the  extirpation  of  a  postnasal  polyp. 

The  Pathogenesis  of  Nasal  Polypi. — Some  account  may  now  be 
given  as  to  the  ideas  in  regard  to  the  etiology  and  ])athology  of 
the  nasal  polyp.  A  singular  conception  of  the  etiology  and  patho- 
genesis of  the  polyp,  in  pre-Schneiderian  days,  may  be  found  in 
Forestus.  In  spite  of  the  monstrous  error  of  conception,  we  may 
perhaps  recognize  the  germ  of  the  idea  which  subsequently  became 
the  accepted  one  until  the  rise  of  the  myxoma  mistake  in  the  last 
half  of  the  nineteenth  century.  Forestus,  writing  in  the  last 
years  of  the  sixteenth  century,  mentions  (1.  c.)  the  remarkable 
case  of  a  woman  in  whose  nostrils  a  huge  polyp  had  grown  "due 
to  her  carrying  heavy  weights  on  her  head;  it  forced  the  mucus 
down  into  the  membranes  of  the  nose."  She  was  cured  by  ligation 
of  the  polyp  and  the  application  to  its  stump  of  vitriol;  but  when 
she  resumed  her  occupation,  it  again  returned  and  was  again  cured 
in  the  same  way. 

Previous  to  the  eighteenth  century  nasal  polypus  was  still  a 
A'ery  comprehensive  term,  and  ^  an  Meckren-'  even  ga\'e  that  name 
to  a  piece  of  wood,  covered  by  granulations,  which  was  expelled 
from  the  nose  of  a  patient  he  was  treating  l)y  local  applications." 

Passing  over  a  hundred  years  from  Forestus,  and  beyond  the 
advent  of  the  Schneiderian  anatomy,  we  find  the  idea  modified  by 

^  Traite  des  Operations  dv  Chirutgic,  Paris,  J 742,  p.  4oo;  Observalions  de 
Chirurgie,  1731. 

-  Chirurgical  Observations,  London,  177;5,  p.  43. 

'  Osphn'siologie,  p.  (JtiS. 

■•  Traite  des  Operations,  Paris,  1731,  T.  3,  p.  .^2.  obs.  V.  Garengeot  does  not 
state  which  of  several  I'reneh  writers  l)efore  him  of  this  name  he  refers  to. 

^  Observationcs  Medira(>  Chirurgieae  in  Latinuni  translatae  ab  lilasio,  1682. 

^  The  earliest  account  of  a  rhinolith  I  have  noted  is  by  Thos.  Bartholinus. 
It  is  referred  to  by  Cloquet:   Osphresiologic,  p.  627 


166  INTRANASAL  SURGERY  AND  PATHOLOGY 

Saint  Hilaire.^  "  The  polypus.  When  this  excrescence  is  hard 
and  is  not  pendent  they  call  it  sarcoma,  which  is  a  great,  round 
tumor,  which  has  not  a  root  like  the  polypus;  moreover,  sarcoma 
always  commences  at  the  lower  part  of  the  nostrils,  and  the  polyp 
takes  its  origin  in  the  osseous  lamellae  at  the  root  of  the  nose.  In 
order  to  well  understand  the  cause  of  this  excrescence,  it  is  neces- 
sary to  observe  that  the  internal  membrane  of  the  nose  is  ^'ery 
thick  and  spongy,  and  is  bathed  in  a  sticky,  viscid  humor,  and  its 
porosities  are  so  arranged  that  it  only  gives  passage  to  those  parts 
of  the  blood  which  are  the  thickest  and  most  likely  to  produce 
excrescences.  All  these  causes  joined  together  contribute  greatly 
to  the  generation  of  polypi.  Whenever  a  little  heat  and  disturb- 
ance get  into  the  blood,  its  movement  increases,  its  viscid  parts 
are  extruded,  the  heat  fixes  them  and  condenses  them,  and  their 
abundance  in  a  part  as  spongy  as  the  nose,  furnishes  the  substance 
of  the  poh'p,  because  these  humors  becoming  arrested  in  the 
tissue  of  this  membrane,  they  swell  its  vessels  and  dilate  its  glands; 
the  matters  congeal,  and  are  changed  into  a  fungous  and  car- 
cinomatous mass  and,  by  the  addition  of  new^  matter,  the  polyp 
enlarges  and  grows.  The  polyp  indeed  may  also  be  engendered 
by  an  acrid  lymph,  which  erodes  the  glands  and  the  channels  of 
the  internal  membrane  of  the  nose  in  such  a  manner  that  the 
nutrient  juice,  becoming  infiltrated  by  the  ulceration  of  this  mem- 
brane into  the  interstices  of  its  fibers,  coagulates  there  and  forms, 
little  by  little,  those  excrescences  which  they  call  polypi.  One 
may  again  attribute  the  cause  of  these  excrescences  to  the  little 
glands  of  the  membrane,  which,  in  dilating,  become  joined  together 
and  form  that  which  we  call  polypus.  The  acidity  of  the  humors 
may,  indeed,  contribute  to  the  generation  of  these  excrescences, 
because  it  can  coagulate  the  nutrient  juice,  which  become  lodged 
in  the  glands,  remains  there,  having  lost  its  fluidity,  and  new  juice 
flowing  there  and  coagulating,  it  forms  a  tumor  in  the  nose,  which 
they  call  a  polyp." 

1  am  sure  1  may  be  pardoned  for  giving  room  to  this  verbose 
and  confused  extract,  because  it  illustrates  very  well,  indeed,  the 
new  light,  as  yet  but  little  appreciated,  which  had  been  shed  over 
medicine  by  the  discovery  of  the  circulation  of  the  blood  and  the 
lymph,  and  by  the  demonstration  of  the  glands  as  well  as  by  the 
anatomical  researches  of  Schneider.  Through  it  all  there  runs  the 
influence  of  both  the  iatrochemical  and  the  iatrophysical  school. 

Although  he  practically  adopts  the  classification  of  Hippocrates, 
mentioning  five  kinds  of  polypi,  Dionis,-  the  first  edition  of  whose 
surgical  work  was  published  in  1707,  makes  this  distinction  between 
two  varieties:    "One  is  an  excrescence  formed  by  the  engorgement 

'  L'Anatomie  du  Corps  Ilumain.  Par  le  Sieur  de  Saint  Hilaire,  1698. 
Tome  I,  p.  43  .    Des  maladies  du  nez. 

2  Cours  d'Op(5rations  de  Chirurgie.    Bruxelles,  1708,  p.  392. 


THE  ANATOMY  OF  THE  ACCESSORY  NASAL  SINUSES     167 

of  the  glands  which  Hne  the  walls  of  the  pituitary  membrane,  and 
the  other  is  the  extension  of  this  membrane  gradually  elongated." 
One  has  only  to  read  Boerhaa\'e  and  Morgagni  to  perceive  that 
they  also  had  the  idea  of  a  membrane  clogged  with  humors. 
Boerhaave  in  his  Institutiones^  could  only  account  for  the  formation 
of  a  polypus,  by  supposing  that  the  nasal  passages  and  the  sinuses 
becoming  clogged  with  inspissated  mucus,  the  mucous  membrane 
was  unable  to  discharge  its  humors.  Popular  belief  in  the  reality 
of  lunar  influences,  a  lingering  of  primeval  superstition,  is  reflected 
in  the  works  of  Juncker-  in  his  references  to  this  subject.  He  says, 
that  according  as  the  moon  fills  or  wanes,  the  polypi  of  the  nose 
increase  or  decrease  in  size.  "Hence  it  may  be  concluded  it  is 
best  to  attack  the  polyp  in  the  waning  of  the  moon."  After  this 
it  is  necessary'  to  add  that  he  was  a  respected  and  distinguished 
medical  writer  in  his  day. 

Gorter^  speaks  of  nasal  polypus  thus:  "It  seems  sufficiently 
evident  that  the  pituitary  membrane  is  separated  from  the  bone, 
often  carious,  in  the  cavity  of  the  nostrils,  so  that  it  makes  a 
pendulous  sac,  either  single  or  multiple,  according  as  this  membrane 
is  separated  from  one  or  more  depressions  of  the  small  bones,  which 
sacs  swell  with  secretions  collected  in  the  cellular  lamellse  of  the 
membrane." 

Heister,^  the  great  German  surgeon  of  the  eighteenth  century, 
adopts  this  pathology,  and,  referring  to  the  earlier  work  of  Palfin, 
who  had  made  the  same  observation,'^  he  speaks  of  polypi  springing 
from  the  accessory  sinuses  and  the  cavities  of  the  ethmoid. 

Morgagni,^  while  accepting  this  view,  differentiates  much  more 
intelligibly  than  previous  writers  the  various  phases  of  intranasal 
disease.  Referring  to  cases  of  polypi  of  the  maxillary  antrum 
reported  by  Meckren  and  Palfin,  he  says  that  they  are  much  more 
frequently  seen,  at  postmortem,  outside  than  inside  the  sinuses. 
He  describes  hypertrophies  at  the  lower  border  of  the  inferior  tur- 
binated bones,  which  he  regarded  as  glandular,  doubtless  more  on 
account  of  their  nodular  surface  than  on  account  of  histological 
findings,  of  which  nothing  was  yet  known  in  these  cases. 

The  Anatomy  of  the  Accessory  Nasal  Sinuses. — We  will  now  turn 
to  the  accessory  sinuses  which  have,  of  late  years,  assumed  a  position 
of  such  striking  interest  in  rhinology  that  they  deserve  a  special 

^  Boerhaave's  Academica,  Lectures  on  the  Theory  of  Physic,  being  a  genuine 
translation  of  his  Institutes,  London,  1751-57,  vol.  IV,  footnote,  p.  28. 

-  Conspectus  Chirurgiae,  Halae,  1721,  p.  236. 

3  Chirurgia  Repurgata,  Lugd.  Batav.,  1742,  §  882,  p.  201. 

« Chii-urgie,  1743. 

s  A  sm-geon  of  Paris  once  told  me  he  had  seen  a  polyp  which  had  its  attach- 
ment within  the  cavity  of  the  os  maxillare  and  had  grown  through  the  hole 
of  communication  into  the  nose;  this  he  had  observed  after  death.  Palfin, 
Anatomic  du  Corps  Humain,  II  me  partie,  Cap.  15,  edit.  1726,  p.  92. 

*  De  Sedibus  et  Causis  Morborum.  Lib.  I,  Epist.  XIV,  Venetiis,  1761,  I, 
p.  108  et  seq. 


168  INTRANASAL  SURGERY  AND  PATHOLOGY 

notice  of  their  anatomy,  physiology,  and  pathology.  Notwith- 
standing that  (lalen  refers  in  several  ])laeesi  to  the  porosity  of 
the  bones  of  the  head  making  them  of  little  weight,  there  is  no 
direct  reference,  so  far  as  1  can  discover,  to  the  sinnses.  As  we 
have  noted,  Berengar  described  them,  and  he  is  credited  with  being 
the  first  definitely  to  indicate  their  existence.  Vesalius'-  described 
the  maxillary,  frontal,  and  sphenoidal  siiuises,  and  asserted  that 
they  contain  nothing  bnt  air.  Both  he  and  Fallopins  (Institut. 
Anatom.),  in  cjnoting  Galen,  leave  the  impression  that  the  latter 
had  definitely  noted  the  accessory  sinuses.  They  agree  with  him 
in  explaining  the  porosity  of  the  bones  of  the  head  as  having  been 
created  to  render  them  less  heavy.  Massa,  who  wrote  before 
Vesalius'  work  saw  the  light,  also  entertained^  this  \iew.  We  have 
noted  that  Colombo  suggested  the  name  Amjiullosum  for  the  os 
maxillare  on  account  of  its  sinus.  After  Berengarius,  Fallopius^ 
first  added  materially  to  our  knowledge  of  the  accessory  sinuses. 
Describing  the  sphenoidal  sinus,  he  says:  "There  is  no  cavity  in 
children  until  they  arrive  at  maturity.  In  adults,  however,  it  is 
found  double  and  sufficiently  large.  It  begins  to  form  after  the 
first  year.  .  .  .  Those  cavities,  contained  in  the  frontal  and 
cheek  bones,  are  not  to  be  found  in  the  skulls  of  the  newlv  born." 
After  criticising  some  erroneous  opinions  which  certain  anatomists 
have  entertained  in  regard  to  the  sphenoidal  sinus,  he  says:  "The 
third  oj)inion  is  that  they  serve  for  holding  the  air  before  it  enters 
the  brain.  This,  while  a  more  respectable  opinion,  becomes  ridicu- 
lous in  view  of  their  absence  in  infancy,"  and  he  adds  the  sage 
remark:  "Ex  his  colligo  licere  cuique  philosophari,  at  non  semper 
sine  errore."  In  another  trite  Latin  sentence  he  accepts  the  idea  of 
Galen:  "Nam  natura,  cum  vult  extendere  et  non  addere  materiam, 
inflat  et  faciat  ut  illae  partes  sint  leviores."  Notwithstanding  the 
fact  that  tins  ancient  view  is  still  the  accepted  one,  so  far  as  we 
at  present  indulge  in  any  teleological  speculations  at  all,  there  haAC 
always  been  numerous  divergences  of  ojiinion  as  to  the  uses  of 
these  cavities.  Thus  Veslingius'^  says:  "There  is  much  doubt  as 
to  their  use.  Each  one  forms  his  own  conjectures.  Some,  as 
Placentinus,  claim  they  contain  mucous  humor  which  is  distilled 
into  the  nares;  others  that  they  serve  to  make  the  voice  more 
resonant,  because  in  those  who  speak  badly  they  are  not  found. 
Some  think  the  air  is  elaborated  in  them  for  the  generation  of  the 
animal  sj)irits.  S])igclius  thinks  they  are  for  drawing  in  the  odors. 
Others  think  they  contain  the  humor  by  which  the  eyes  are  moist- 
ened and  lubricated."     He  himself  accepted  the  view  of  Galen. 

1  As  for  insfimfc  Dc  T'sii  Parliuni  IX,  2  et  scq.,  (Kiihii)  III,  ]).  (301. 

-  Dc  lIuiiKiiii  Corporis  I'uhrica,  Lib.  I,  Cap.  V'l-IX. 

^  Epist.  Med.  et  Philosoj)li.,  1.342.    Kpist.  V.,  Venetiis,  15.30,  p.  55. 

■*  Gabrielis  Fallopii:    Obs.  Anatom,  Francofurti,  1600,  p.  307. 

^  Syntagma  Anatomicum,  Aj^pendix,  Pans  XIX,  1637. 


THE  ANATOMY  OF  THE  ACCESSORY  NASAL  SINUSES     1G9 

A  reference  to  Spigelius^  will  show  that  he  doubted  their  adding 
any  quality  to  the  voice,  a  function  ascribed  to  them,  however, 
by  Bartholinus,  who  asserted-  they  were  not  present  in  those  of  a 
faulty  voice.  Both  Fallopius  and  Veslingius,  as  well  as  Jessen 
(1601),  supposed  they  were  also  instrumental  in  the  generation 
of  the  animal  spirit.  Jessen  and  Bartholinus  believed  the  frontal 
sinus  contained  a  viscid  liquid,  which  lubricated  the  eyeball.  Paaw^ 
speaks  of  the  frontal  sinus  as  containing  a  viscid  matter,  not 
dissimilar  to  the  substance  of  the  brain,  but,  "far  more  likely  in 
my  opinion  is  the  use  of  this  cavity  that  of  receiving  the  air  drawn 
through  the  nostrils  into  it,  so  that  it  may  be  better  assimilated 
and  prepared  for  the  brain.  Unless  it  is  thus  properly  prepared 
by  this  and  other  sinuses,  the  ingress  of  this  crude  and  imprepared 
air  causes  catarrhal  troubles  of  the  brain."  These  opinions  of 
more  original  observers  are  reflected  in  a  curious  book^  on  anatomy 
published  in  English,  evidently  for  popular  use,  by  a  Dr.  Alexander 
Read,  in  1642.  He  speaks  of  the  frontal  sinuses  as  double  in  child- 
hood, but  one  in  those  of  ripe  age.  "These  cavities  contain  a 
clammy  substance,  kept  in  by  a  green  membrane.  They  are  for 
the  retention  of  the  odor,  before  it  is  carried  into  the  brain."  As 
for  the  sphenoidal  sinus,  he  says,  "there  is  a  cavity  like  to  those 
above  the  eyebrow,"  but  he  speaks  of  the  ethmoidal  as  furnishing 
a  way  for  the  excretions  of  the  brain.  Schneider's  works  finally 
revolutionized  all  this.  He  declared  that  the  sinuses  had  nothing 
to  do  with  the  animal  spirit  and  were  empty.  The  latter  opinion, 
however,  made  its  way  very  slowly.  Almost  a  hundred  years 
after  Schneider,  the  great  Boerhaave  declared,  in  his  lectures, 
not  only  that  acuteness  of  smell  largely  depended  on  the  size  of 
the  frontal  sinus,  their  presence  allowing  a  greater  extent  to  the 
pituitary  membrane,  but  he  also  was  of  the  opinion  that  they  acted 
as  reservoirs  for  the  nasal  secretions.  He  remarks  that  the  reason 
why  children's  noses  are  always  running,  is  that  the  accessory 
sinuses  are  not  sufficiently  developed  to  contain  the  mucus.  j\Iuch 
of  Boerhaave's  nasal  pathology  was  based  on  this  conception. 
The  fluid,  which  the  earlier  anatomists  supposed  they  contained, 
was  thought  to  have  come  from  the  brain.  After  the  publication 
of  Schneider's  works,  Diemerbroek  still  believed,  as  has  been  stated, 
that  it  came  from  the  brain,  but  through  the  mucosa  which  lines 
the  nose  and  its  cavities,  thus  keeping  the  latter  full.  Vieussens 
(born  1641)  supposed  they  contained  a  thick  fluid,  filtered  out  of 
the  blood  on  its  way  to  the  brain.     Much  later  the  great  Ilallcr^ 

1  De  Human.  Corp.  Fabr.,  Opera  Omnia,  1G45,  p.  35. 

2  Anatomia     .     .     .     J^'t'oiinata.    Hagae  Com.,  KKiO,  p.  488. 
^  De  Human.  Corp.  Ossibas.,  Amst.,  1633,  p.  37-38. 

■*  The  Manual  of  Anatomy,  or  Dis.section  of  the  Body  of  Man,  London,  1642, 
p.  397. 

5  Elementa  Phvsiologiaj  Corporis  Humani.  Liber  XIV,  §  5,  Lausanne,  1763, 
V,  p.  ISO 


170  INTRANASAL  SURGERY  AND  PATHOLOGY 

in  the  eighteenth  century  accepted  this  view,  intimating  they 
were  reservoirs  for  lubricating  the  nasal  mucosa.  Wrheyen  (1648- 
1710)  had,  however,  previously  asserted  they  were  empty.  Rein- 
inger  partook  of  the  view  of  Ilaller,  saying  the  sinuses  were  so 
arranged  as  to  the  nasal  cavity  that  whatever  position  we  are  in, 
their  contents  will  drain  out  of  one  or  more  of  them,  collecting 
in  the  others,  until  they  in  their  turn  are  emptied  by  a  change  of 
position,  ^lorgagni'  declared  the  maxillary  sinus  was  occasionally 
absent.  Weinhold  (1783-1829)  thought  the  sinuses  were  cavities, 
which  suck  the  impurities  out  of  the  blood  and  hold  them,  and 
that  they  are  to  be  regarded  as  the  equalizing  apparatus,  the 
"equatorial  bearers"  of  the  arterial  system  throughout  the  animal 
kingdom.-  The  frequency  with  which  the  accessory  sinuses  have 
lately  been  found,  postmortem,  to  contain  sero-  or  muco- 
purulent fluid,  satisfactorily  accounts  for  this  divergence  of  views. 
A  more  palpable  error  was  committed  by  Spigelius,  Bauhinus, 
Laurentius,  Paaw,  and  many  others  in  supposing  that  the  sinuses 
are  lined  by  a  green  membrane.  It  was  pointed  out  by  Schneider 
that  this  condition  was  entirely  due  to  postmortem  changes. 

Wounds  of  the  Accessory  Nasal  Sinuses. — Early  surgeons  were 
familiar  with  the  wounds,  but  not  with  the  diseases  of  the  frontal 
sinus.  Hence  we  find  at  first  no  reference  to  the  intentional  opening 
of  it,  but  evidently  it  was  occasionally  inadvertently^  included  in 
the  field  of  operation  in  trephining  for  cranial  fractures.  Ambroise 
Pare,^  speaking  of  the  wounds  of  the  head,  warned  against  trephin- 
ing the  frontal  sinuses,  as  they  are  "  filled  with  white,  sticky  fluid 
as  well  as  with  air."  Elsewhere*  he  says  that  he  had  seen  a  surgeon 
trephine  the  sinus,  in  wounds  of  it,  under  the  impression  the  brain 
was  injured.  "  Wherefore  it  is  necessary  for  the  surgeon  to  become 
acquainted  with  this  cavity,  which  he  can  do  by  breaking  open 
several  heads  of  the  dead." 

Fabricius  Ilildanus  (1.  c.)  speaks  of  wounds  of  the  frontal  sinuses 
"  not  healing  easily  and  often  degenerating  into  fistulae  and  malig- 
nant ulcers."  "The  wounds  of  these  cavities  have  such  a  large 
communication  with  the  eyes,  that  I  have  seen  acrid  and  corrupted 
pus,  which  flows  from  these  cavities,  fall  upon  the  conjunctiva 
and  push  the  eye  out  of  place."  Verheyen^  says  that  he  was  once 
present  at  an  operation  on  a  sheep,  for  the  removal  of  worms  from 
the  frontal  sinus,  but  the  animal  died  because  the  operation 
was  too  extensive.  Palfin  had  seen  the  same  mistake  as  Pare,  and 
his  differential  points  to  distinguish  the  frontal  sinus  from  the 
cerebral  cavity  in  wounds  of  the  head  were:  (1)  "When  one  sees 

1  Adversaria  Anatom.,  Lugd.  Batav.,  1723,  I,  p.  38,  VI,  p.  IIG. 

'  The  incompleteness  in  the  references,  to  be  here  noted,  may  be  supplied 
by  referring  to  the  much  more  exhaustive  history  given  by  Zuckerkandl, 
Normale  und  i)athologische  Anatomie  der    Nasenhohle.     Wien.,  1893,  I,  p.  1 . 

3  Chirurgie,  Livre  X,  Chap,  21,  Edit.  1564.  ■•  Livre  V,  Chap.  4. 

*  Quoted  by  Palfin:  Anatomie,  Paris,  172G,  part  11,  p.  93. 


WORMS  IN  THE  ACCESSORY  NASAL  SINUSES  171 

mucus  coming  out  of  the  wound.  (2)  When  air  is  blown  from  the 
wound  by  expiratory  effort  with  closed  mouth  and  nose.  (3)  The 
penetration  of  injected  bitter  water  from  the  wound  to  the  throat, 
or  (4)  its  discharge  from  the  nose."  He  relates  several  interesting 
cases  where  this  mistake  was  made. 

Worms  in  the  Accessory  Nasal  Sinuses. — The  remark  of  Verheyen, 
in  regard  to  worms  in  the  frontal  sinus  of  a  sheep,  finds  a  precedent 
in  human  pathology  in  the  observation  of  Beniveni,  published  as 
early  as  1507.^  He  relates  the  case  of  a  friend  of  his  by  the  name 
of  Phillip,  who  suffered  atrociously  with  such  pain  in  the  head 
that  his  eyes  grew  dim,  his  mind  wandered,  vomiting  occurred, 
the  voice  was  lost,  the  body  was  cold,  and  even  life  itself  seemed 
lacking;  but  when  death  really  seemed  imminent  and  there  seemed 
no  help,  he  suddenly  passed  from  his  right  nostril  a  worm  as  long 
as  a  palm's  breadth,  and  of  a  most  robust  nature,  and  all  his  anguish 
was  relieved. 

Morgagni,^  referring  to  Littre  as  having,  in  1704,  conceived  the 
idea  of  trephining  the  frontal  sinuses,  says  that  Mangetus,  accord- 
ing to  Vallisnieri,  had  performed  the  operation  for  the  removal  of 
a  worm  whose  presence  he  had  diagnosticated  as  giving  the  patient 
great  pain.  According  to  Cloquet,^  Vallisnieri  was  the  first  who 
spoke  of  worms  in  sheep's  noses  from  the  true  stand-point,  but 
IMorgagni,  speaking  of  worms  being  frequently  found  in  sheep's 
noses  and  rarely  in  man's,  credits  Fernelius^  with  having  first 
declared  that  the  brain  was  not  the  origin  of  worms  in  the  nose. 
This  subject  of  worms  in  the  nose  was  exhaustively  discussed  in 
the  first  part  of  the  eighteenth  century  by  Salzmann  and  Honold.^ 

The   following   is   from    Boerhaave's   Institutiones"    No.    792 .-^ 

"There  was  a  distressing  example  of  a  girl  at  Rotterdam,  whose 
six  pituitary  sinuses  were  all  full  of  worms,  which  kept  on  growing 
and  appeared  from  hour  to  hour;  and  this  girl  I  cured  by  a  slight 
fumigation  with  cinnabar  and  a  decoction  of  tobacco  in  water 
which,  being  snuffed  up  the  nose,  obliged  the  worms  to  move  their 
quarters." 

Perhaps  the  earliest  reference  to  what  may  have  been  sinus 
suppuration  is  to  be  found  again  in  Fernelius:  "There  forms 
sometimes  abscesses  around  these  places  without  fever  or  very 

1  Antonii  Benivenii,  De  Abditis  Nunnullis  ac  Mirundis  Morborum  et  Sana- 
tionum  Causis.    Flor.,  1507. 

2  De  Sedibus  et  Causis  Morborum.  De  Morbis  Capitis,  Epist  Anatom.  Med., 
XIV,  sec.  20  et  seq.  1761,  I,  p.  115. 

^  Osphresiologie,  p.  (317,  note. 

*  Fernelius,  born  in  1497,  died  1538,  was  the  physician  who  cured  the  beau- 
tiful but  frail  Diana,  of  Poitiers,  and  is  said  to  have  been  the  first,  since  the 
time  of  Al-Mamum,  the  Arab  (876-838),  to  calculate  the  circumference  of  the 
globe. 

^  De  Verme  Naribus  Excusso.  In  Haller's  Disputat.  ad  Morb.  Hist.,  1721, 
I,  385. 

8  Acad,  lect.,  V,  p.  487. 


172  INTRANASAL  SURGERY  AND  PATHOLOGY 

much  pain,  and  after  thoir  nii)turo  I  have  seen  true  pus  run  in 
abundance  from  the  nostrils,  as  it  comes  out  of  purulent  ears,  and 
this  without  any  jjrejudice  to  the  <;eneral  health."  !\lor<;a^ni  (1.  c), 
from  whom  I  have  quoted  this  extract,  comments  on  it,  saying 
that  doubtless  Fernelius  was  referrin<i;  to  the  accessory  sinuses, 
"for  how  could  a  man  like  him  sup])()se  the  pus  came  from  the 
anterior  cavities  of  the  brain?"  One  mi^dit  answer,  that  without 
the  anatomical  knowledge  supplied  by  Schneider  101)  years  later, 
it  would  have  been  strange  if  Fernelius  thought  of  the  pus  or  the 
worms  either,  as  having  come  from  any  place  but  the  brain.  One 
is  therefore  not  surprised  on  turning  to  the  passage,'  evidently 
referred  to  by  Morgagni,  to  find  no  warrant  for  supposing  that 
Fernelius  suspected  the  true  origin  of  the  pus  or  the  worms.  His 
work  aj)peared  first  in  1567. 

Surgery  of  the  Maxillary  Sinus. — Nathaniel  Highmore,  in  1651, 
described-  the  sinus,  which  l)ears  his  name,  and  gave  some  poor 
representations  of  it.  He,  however,  mentions  a  case  of  suppurative 
disease  of  the  cavity  in  a  woman  who  had  some  bad  teeth  in  the 
upper  jaw.  Tliis  was  before  the  publication  of  Schneider's  work, 
though,  as  we  have  seen,  the  sinuses  had  long  been  well  known. 

Velpeau^  quotes  ]\Iolinetti,  who  wrote  in  1675:  "In  a  patient 
sufi'ering  from  terrible  pain,  they  made  a  (external)  crucial  incision 
on  the  jaw,  and  with  the  crown  of  the  trephine  penetrated  into  the 
antrum  of  Highmore,  which  was  the  seat  of  the  abscess." 

IMorgagni  intimates  that  Jean  Henry  ]\Ieibomius,  who  died  in 
1655,  invented  what  we  now  know  as  Cowper's  operation  for 
opening  the  maxillary  antrum,  and  his  son  practised  it.  ^'elpeau 
says  that  Zwingler,  before  Meibomius,  pulled  out  teeth  and,  dilating 
the  alveoli  with  a  sj)onge,  made  exit  for  pus  from  the  antrum.  There 
were  three  medical  authors  by  the  name  of  ^Meibomius,  apparently 
difi'erent  generations,  but  their  works,  as  well  as  that  of  Zwingler, 
are  inaccessible  to  me.  William  Cowper  contributed  the  chapter 
on  the  diseases  of  the  nose  to  Dr.  Drake's  "  Anthropologia  Nova," 
which  was  published  first  in  1717,  and  there^  is  to  be  found  the 
description  of  the  oi)eration  as  we  know  it.-^  "...  By  all 
which,  it  appears  with  what  difficulty  any  peccant  liumor,  lodged 
in  either  of  these  cavities,  can  be  discharged  by  the  foramina  narium, 
since  these  cavities  must  be  either  filled  up  to  the  toj)  read\-  to  run 
over  first,  or  the  head  must  be  held  down  to  procure  the  discharge. 
This  induced  me  to  put  into  practise  an  operation,  in  the  cure  of 

*  .Johanni  Fornclii  Anibiani,  Do  Morbis  Universalibus  et  Particularibus, 
Edit.  1650,  Lib.  V,  Cap.  \II. 

2  Corpori.s  Humani  Disqiiisitio  .\nat.,  Ilagse  Com.,  1651. 

•■'  Xouveaux  Ek'monts  do  Modecino  Oponxtoiro,  Paris,  1S39,  III,  p.  008. 

••  Drake,  .J.,  Antlicjpologia  Nova.   Hook  III,  Cap.  10,  London,  1717,  II,  p.  305. 

5  From  the  f-jjolling  which  is  usually  omi)loyed  (Cooper)  doubtless  many 
have  attributed  this  operation  to  Sir  Astley  Coojut,  who  lived  a  hundred  years 
later. 


SURGERY  OF  THE  MAXILLARY  SINUS  173 

ozsena,  which  appeared  reasonable  to  me  by  the  structure  of  the 
part,  I  being  convinced  it  might  be  done  without  hazard  to  the 
patient.  After  the  foremost  Dens  iMolaris  was  taken  out,  not 
finding  an  aperture  from  its  alveohis  into  the  antrum,  which  in 
other  instances  I  have  seen  happen,  with  a  convenient  instriunent 
I  bored  the  hole  of  the  alveolus  into  the  Antrum  Genfe,  whereby 
the  pus,  which  before  lay  in  the  antrum,  ran  out,  and  the  medicines 
that  were  daily  injected  by  this  aperture  passed  into  the  nostrils, 
whereby  the  patient  was  cured,  though  this  disease  had  continued, 
with  a  vast  flux  of  stinking  matter  daily  from  the  nose,  for  more 
than  four  years  before  the  operation."  Besides  another  case 
operated  on  in  the  same  way,  he  relates  the  history  of  an  old  man 
in  whom  the  maxillary  antrum  was  opened.  Carious  bone  came 
away  with  the  teeth,  when  extracted,  and  the  man  soon  died  from 
convulsive  disorders,  when,  on  post  mortem,  a  fistulous  tract  was 
found  through  the  Foramen  Lacerum;  the  opposite  side  of  the  os 
sphenoides  was  also  perforated  and  the  dura  mater  laid  bare  l)ut 
not  perforated;  but  on  the  contrary  it  was  inflamed,  and  very  much 
thickened  on  that  side  of  the  head:  "I  found  an  aposthemation 
in  the  cortical  substance  of  the  forepart  of  the  hinder  lobe  of  the 
brain,  though  covered  with  pia  mater,  in  which  was  about  an  ounce 
of  fetid  matter."  He  also  first  suggested  the  perforation  of  the 
antrum  on  its  anterior  surface.  According  to  Portal,^  Lamorier, 
a  surgeon  of  ]\Iontpelier,  born  in  1717,  proposed,  as  the  result  of 
his  own  investigations,  to  open  the  sinus  more  posteriorly,  between 
the  malar  tuberosity  and  the  third  molar  tooth.  Jourdain,  a 
Paris  dentist,  in  1765  reported  to  the  lloyal  Academy  of  Surgery 
of  Paris  a  method  of  washing  out  the  Antrum  of  Highmore  through 
the  natural  opening.-  He  also  is  credited  with  the  observation, 
which  of  late  has  again  been  brought  into  prominence,  that  fetitl 
matter  is  often  found  in  the  maxillary  sinus  of  those  who  had 
succumbed  to  adynamic  or  ataxic  fevers.  For  opening  the  sinus 
Desault  used  a  sharp  triangular  perforator,  Ivunge  used  a  knife, 
and  Chas.  Bell  a  trephine.  I  further  translate  from  ^>lpeau  the 
following:  "In  a  patient,  who  had  no  longer  any  molar  teeth,  the 
idea  occurred  to  Gooch''  to  ])erforate  the  Antrum  of  Highmore 
from  its  nasal  surface.  This  method  was  also  proposed  by  John 
Hunter  in  his  treatise  on  the  human  teeth  in  1778.  01.  AcreP  had 
already  followed  an  almost  similar  procedure,  that  is  to  say,  after 
operating  in  the  manner  of  Cowper  he  placed  a  second  canula 
through  the  nose  into  the  sinus.  ...  A  buccal  fistula  of  the 
maxillary  sinus  suggested  to  Ruft'eP  the  idea  of  penetrating  there 

^  See  Velpeau,  1.  c,  who  gives  a  very  exhaustive  account  of  the  earlier  Ktera- 
ture,  but  unfortunately  witliout  exact  references. 

-  Journ.  de  Med.  Chir.  Pharm.,  etc.,  Paris,  1767,  XXVII,  52,  157. 
'  An  l']n<ilish  surgeon  who  died  in  1780. 

*  A  Swedish  surgeon  hoi'u  in  1707  and  died  at  90  years  of  age. 

*  I  can  find  no  other  reference  to  a  phj-sician  of  his  name. 


174  INTRANASAL  SURGERY  AND  PATHOLOGY 

with  a  perforator,  making  it  come  out  above  the  gum  in  order  to 
establish  a  counter  opening.  A  seton  was  then  passed  and  kept 
in  the  opening  for  six  weeks,  working  so  well  that  success  crowned 
the  efforts  of  the  surgeon.  Callisen  (1740-1824)  followed  this 
plan.  .  .  .  Bausch  and  Henkel  succeeded  by  passing  a  seton 
through  a  fistula  in  the  floor  of  the  orbit  and  bringing  it  into  the 
mouth  through  an  alveolus.  Bertrandi  resorted  to  a  like  plan, 
not,  however,  using  the  seton.  Weinhold  (1810?)  went  through 
from  the  upper  part  of  the  canine  fossa  into  the  antrum  and  thence 
through  into  the  palatine  vault.  Jussi  operated  in  much  the  same 
way." 

On  reference  to  Callisen's  work^  I  find  that  he  refers  to  abscesses 
of  the  frontal  and  maxillary  sinuses.  He  advised  operation  by 
trephine  on  the  former,  and  perforation  through  the  canine  fossa 
in  the  latter.  He  advises  that  the  opening  should  be  kept  pervious 
by  a  linen  tent,  or  a  sponge,  or  a  tube  made  of  elastic  resin,  (resins 
elasticae — rubber?)  or  of  gold,  so  arranged  that  it  will  not  slip  into 
the  cavity.  He  declared  that  penetration  through  the  hiatus  semi- 
lunaris, as  recommended  by  Jourdain,  is  often  im])ossible.  He  was 
also  familiar  with  polypi  in  the  Antrum  of  Highmore.  I  am  sure 
anyone,  reading  these  accounts  of  operations  on  the  Antrum  of 
Highmore  for  suppurative  disease,  will  perceive  that  all  the  recent 
procedures,  which  have  been  of  late  so  exhaustively  and  frequently 
described,  have  been  long  anticipated  in  surgery.  Tumors  of  the 
maxillary  sinus  Ave  have  noted  as  having  been  reported  by  Palfin 
and  others.  Van  Ruysch  reported  finding  two  at  post  mortem.^ 
In  the  Journal  de  Desault  in  1791  is  an  account  of  an  operation  of 
considerable  gravity  by  Plaignaud,  in  1784,  on  a  tumor  of  the 
maxillary  antrum  which  was  successful.^  Another  case  is  reported,'' 
in  which  the  disease  was  allowed  to  pursue  its  course  unmolested, 
and  the  patient  died  three  years  after  its  inception. 

Diseases  and  Surgery  of  the  Tonsils.- — It  remains  to  say  something 
in  regard  to  disea'ses  of  the  tonsils  during  the  period  with  which 
we  have  been  dealing.  Very  little  advance  is  here  to  be  noted. 
Besides  the  hypertrophy,  disease  of  the  tonsillar  structure  is  rarely 
alluded  to  independently  of  acute  throat  inflammations.  Sydenham 
incidentally  made  the  singular  remark,  but  doubtless  well  founded, 
that  red-haired  people  were  more  liable  to  tonsillar  inflammation 
than  others.  Ettmiiller,^  in  his  remarks  on  inflammation  of  the 
tonsil,  draws  attention  to  the  gaping  of  the  foramina.  "  On  account 
of  this,"  says  he,  "when  these  tonsils  are  swollen  and  more  or  less 
inflamed  these  foramina  gape  and  are  more  conspicuous,  so  that 
they  are  taken  for  ulcers  by  the  inexperienced  surgeons."    Fallopius 

'  Systema  Chirurgiae  Hodiemac,  Hafniae,  1798,  Vol.  I.  p.  343,  et  seq. 

2  Fredcrici  Ruyschii  Opera  Omnia,  Obs.  LXXVII,  Ainst.,  1737,  Vol.  I,  p.  71. 

3  Jour,  de  Chir.,  par  M.  Desault,  Paris,  1791,  I,  p.  111. 

'  Ibid.  T.  II,  p.  278.  '  Opera  Omnia,  Amst.,  1697,  II,  p.  602. 


PATHOLOGICAL  ANATOMY  175 

had  also  drawn  attention  to  this  point,  still  frequently  the  source 
of  error. 

As  to  operations  on  the  tonsils,  coming  down  as  late  as  the 
middle  of  the  eighteenth  century,  we  find  surgeons  still,  as  ever, 
with  a  wholesome  respect  for  tonsillar  hemorrhage.  Heister's 
category  (1.  c.)  of  operations  on  the  tonsils  is:  (1)  Corrosive  appli- 
cations. (2)  Abscission  according  to  the  methods  of  the  Ancients. 
(3)  Ligation,  using  the  apparatus  of  Hildanus  for  the  uvula. 
Cheselden,  he  says,  applied  such  a  ligature  by  means  of  a  sound. 
Benjamin  Bell  (1.  c.)  employed  his  double  canula  snare  for  ligature 
of  the  tonsils,  in  the  same  manner  as  for  nasal  polypi.  A  method, 
which  he  also  ascribes  to  Cheselden,  was  to  pierce  the  tonsil  with 
a  double-threaded  needle,  and  tie  off  each  half  of  the  tonsil  in  a 
ligature.  Even  such  a  radical  operator  as  Desault,^  although  he 
performed  tonsillotomy  with  an  instrument  he  called  Kiotom 
(Uvulotome),  yet  in  pusillanimous  patients  he  used  a  ligature  put 
on  with  a  forceps,  and  tightened  for  a  dav  or  two  until  the  tonsil 
fell   off. 

Anatomy  of  the  Nose  and  Throat  in  the  Eighteenth  Century. — In 
the  eighteenth  century  but  few  advances  are  to  be  noted  in  the 
gross  anatomy  of  the  nose  and  throat  when  compared  to  the  much 
greater  strides  made  in  the  sixteenth.  Still  there  were  some.  We 
have  already  noted  the  description  of  the  pharyngeal  tonsil  l)y 
Santorini.  He  first  described  the  cartilages  in  the  larynx  which 
have  taken  his  name,  declaring  they  are  found  in  man  but  not  in 
animals.  He  drew  attention  to  the  great  mobility  of  the  crico- 
arytenoid joint,  and  gave  the  first  intelligent  account  of  intra- 
laryngeal  movements. - 

Pathological  Anatomy. — Bertin  described  the  sphenoidal  tur- 
binated bones.^  jNIeckel  and  Ackerman  and  Daniel  wrote  learned 
and  valuable  treatises  on  the  nervous  system  of  the  nose  and  throat.* 
Valsalva  had  written  his  great  work  on  the  ears''  which  was  first 
published  in  1705,  and  described  more  accurately  the  palatal 
muscles,  but  not  his  least  claim  to  fame  in  the  annals  of  medicine 
is  the  fact  that  he  was  the  preceptor  of  ]\Iorgagni,  and  started 
him  upon  that  series  of  observations  at  the  post  mortem  table, 
which  has  resulted  in  the  firm  basis  modern  medicine  now  has  in 
pathological  anatomy.  The  predecessors  of  ^lorgagni  were  too 
much  occupied  with  rare  cases  and  fabulous  histories,  the  curiosities 
of  Medicine,  to  make  much  advance  in  this  direction.  Post  mortem 
examinations  were  not  infrequently  made  in  the  seventeeth  century 
and  even  in  the  sixteenth  century.     Thus  we  find  Tulpius,  who 

1  (Euvrcs  Chirm-gicales,  Pub.  par  X.     Bichat,  Paris,  1798,  II,  p.  202. 

2  Observationes  Anatomica;.     1724,  De  Larynge. 

^  Description  de  deux  os  inconnus,  par  Al.  Bertin,  M6m.  de  L'Academie  dcs 
Sciences,  1744,  p.  29S. 
*  Ref;  Sprengel,  VI,  162. 
5  Valsalvae  Opera.,  Cap.  II,  XIX,  Auris  Descriptio,  Ludg.  Batav.,  1742,  p.  34. 


176  MORGAGM 

rivalled  Boiitekoe  in  his  devotion  to  tea  and  tobacco  as  panaceas, 
describino;'  a  malignant  tumor  of  the  pharynx  and  (rsophao;us 
observed  durinji;  life  and  examined  postmortem.  Incidentally  in 
many  epistles  of  Thomas  Bartholinus  and  of  many  others  there 
are  scattered  accounts  of  the  study  of  lesions  found  postmortem. 
Bonet  is  the  first  who  svstematicallv  recorded-  the  historv  of  cases 
and  the  results  of  observations  on  opening  the  body  after  death, 
l)ut  his  work  is  a  most  verbose,  unclassified,  and  entirely  unreadable 
record  of  much  which  mi<;ht  in  other  hands  have  been  valuable. 
In  it  we  find  the  confirmation  of  Schneider's  observations,  but  in 
his  zeal  to  ])ro\c  that  the  blo()d\-essels  carry  the  nasal  discharo;es, 
he  exajiijeratcs  and  distorts  the  significance  of  anatomical  facts. 
He  taught  that  the  mucus  was  derived  from  the  blood  and  lymph 
vessels  of  the  glandular  mucosa,  and  that  in  the  brain  they  absorbed 
and  carried  away  its  secretions.  Nevertheless,  he  opened  the  way 
for  the  observations  of  Valsalva  and  his  great  pupil,  ^Nlorgagni. 
It  may  be  remarked  that  the  latter  refers  to  Bonet  as  having 
reported  some  cases  of  laryngeal  tumor  observed  postmortem,  but 
T  have  been  unable  to  find  the  reference. 

Morgagni. — Although  the  immortal  "  I)e  Sedibus  et  Causis 
]\lorborum"  was  not  published  in  its  entirety  until  1762,  when 
^lorgagni  was  nearly  eighty  years  old,  his  "Adversaria  Anatomica" 
was  published  when  he  was  a  young  man  (1706  1723).  A  few 
j)oints  of  interest  to  us  may  be  found  in  it.  He  was  somewhat 
influenced  by  ^^an  Ruysclr^  in  his  description  of  the  nasal  glands. 
The  tracheal  glands  first  mentioned  by  Laurentius  he  describes 
more  fully. ^  He  sj)eaks  also  of  the  laryngeal  glands'^  and  made 
the  singular  mistake,  on  noting  the  cuneiform  cartilages,  of  descril)- 
ing  them  as  glands.  This  mistake  many  years  later  was  corrected 
l)y  Wrisberg,*"'  whose  name  they  now  l)ear.  ]\Iorgagni  passes  in 
review^  the  anatomical  facts  brought  to  light  by  early  anatomists 
as  to  the  cartilaginous  frame-work  of  the  larynx.^  Galen  first  noted 
and  described  the  \entricles  of  the  larynx,  gi\'ing  them  that  designa- 
tion, but  ^lorgagni's  name  has  been  attached  to  .them  on  accoinit 
of  his  more  elaborate  description.^  He  also  described  the  Appendices 
Laryngis  A'entriculorum.'-'  He  supposed  that  the  ventricles  are 
instrumental  in  modifying  the  voice,  but  he  warned  against  the 
reasoning  frf)m  animals  like  the  frog  to  man,  \arions  authors  having 
ex{)Iained  their  function  in  this  way.  Nevertheless,  he  thinks  this 
more  probable  than  that  they  form  reservoirs  for  mucus  to  lubricate 
the  cords.     He  ascribes  this  o])ini()n  to  Verheyen.     He  points  out 

'  Observationes  Medicae,  1641,  Lib.  I,  Cap.  44. 

-  Sepulcrctuin  first  edit.,  1()79,  aiiolhcr  aiid  cidargod  edition  bv  ISIangctus  in 
1700. 

^  Advers.  Anatom.  VI,  Animad.,  S9.         '  1.  c.  I.,  25.         M.  c.  V.,  42. 

^  In  the  notes  to  Haller's  Prirnae  Lina'  Pliysiologicie  edited  bj-  Wrisberg,  tliis 
error  was  pointed  out  in  1780. 

"  Adver.  Anat.,  I,  23.  "  I.  c  I.,  l(i.  "  1.  p.  V.,  42,  V.,  43. 


THE  CEREBROSPINAL  FLUID  177 

that  the  surrounding-  mucosa  is  quite  as  well  supphed  with  glands 
as  are  the  ventricles. 

Deviations  and  Spurs  of  the  Nasal  Septum. — When  we  turn  to 
his  more  celebrated  work  we  find  that  the  first  subject  which 
engages  our  attention  in  the  chapter  which  he  devotes  to  the  nose 
and  ear  is  that  of  deviation  of  the  septum.^  Quelmalz-  had  in  1750 
written  a  treatise  on  this  subject,  the  first,  so  far  as  I  know,  of  its 
kind.  It  is  still  a  readable  thesis,  in  which  much  which  is  discussed 
in  modern  rhinological  literature  may  be  found  intelligently  set 
forth.  Among  the  causes  of  the  conditions  he  mentions,  are  pressure 
on  the  nose  in  difficult  labor,  falls  in  infancy,  the  continual  thrusting 
of  the  finger  into  the  nose  in  childhood,  inflammatory  conditions, 
and  others,  which  we  do  not  now  regard  as  efficient.  He  speaks 
intelligibly  of  the  symptoms  and  the  sequelae,  but  says  nothing 
of  the  treatment.  ^lorgagni,  criticising  him  for  not  mentioning 
exuberant  growth  of  the  cartilage,  speaks  of  often  finding  this 
condition  on  postmortem  dissection.  Deviation  of  the  septum, 
he  declares,  is  often  natural,  and  he  warns  observers  against  being 
deceived  by  those  who  write  in  an  absolute  manner  that  the  nose 
is  divided  into  large  equal  cavities  by  an  intermediate  septum. 
On  the  other  hand:  "To  this  error  another  is  opposed  by  those 
who  say  the  septum  is  always  inclined  to  one  side  or  the  other, 
except  in  children."  He  had  seen  in  adults  many  straight  septa. 
Then  follows  the  explanation  of  the  cause  of  deviated  septa  which 
still  holds  good  after  150  years:  "The  too  rapid  growth  of  the 
septum  relative  to  the  other  bones  of  the  upper  jaw,  from  which 
reason  there  necessarily  results  a  curvature."  He  also  described 
very  carefully  a  septal  spur  without  deviation  in  an  old  w^oman. 
I  have  already  had  occasion  to  refer  to  ^Nlorgagni's  ^dews  on  nasal 
polypi  and  his  notice  of  hypertrophies  of  the  inferior  turbinated 
bone,  which  he  regarded  as  glandular. 

The  Cerebrospinal  Fluid. — Bidloo''  had  described  a  case  in  which 
cerebrospinal  fluid  had  escaped  from  the  nose  as  a  result  of  injury. 
St.  Clair  Thomson^  has  quoted  another  case,  reported  previous 
to  this  bv  Willis,^  whose  nervous  fluid  theor\'  Bidloo  earnestlv 
combated.  ]Morgagni''  had  also  seen  such  a  case.  He  was  also 
aware  of  the  existence  of  what  was  afterward  known  as  Jacobson's 
organ,  which  had  been  noted  by  Steno  and  \'an  Ruysch. 

^  The  De  Sedibus  et  Causis  Morborum  has  bc^en  carefully  transUited  into 
French,  Recherches  Anatomiques.  .  .  .  par  Desormeaux  et  Dcsnouet,  and 
some  readers  will  find  it  more  convenient  to  consult  this  ten-volume  edition 
than  the  original  Latin  work.  The  same  references  apply  to  tliat.  See  Des 
Maladies  des  Oreilles  et  du  Nez,  Xo.  16,  Paris,  1S20,  II,  p.  3AS  et  seq. 

-  Programma  de  Narium  earumque  Scpti  Incurvatione.  Haller's  Disputat. 
ad  Morborum  Historiam,  1757,  T.  I.,  p.  377. 

•■'  Excrcitat.  Anat.  Chirurg.,  Decas,  2,  7,  Lugd.  Batav.,  170S,  p.  ISO. 

'  The  Ccrebrosi)inal  Fluid,  London,  1899,  p.  67. 

^  Cerebri  Anatome,  p.  152. 

^  De  Sed.  et  Causis  Mor.,  Lib.  I.,  Ep.  XIV,  p.  21.     He  apparently  did  not 
recognize  it  as  of  cerebral  origin. 
12 


178  THE  PRE-LARYXGOSCOPIC  ERA 

I  will  reserve  INIorgagni's  important  observations  on  laryngeal 
ulceration  nntil  I  have  occasion  to  trace  the  liistory  of  laryngeal 
phthisis,  introducing  here,  however,  his  notice  of  slight  irritation 
in  the  auditory  canal  as  a  cause  for  persistent  cough. ^ 

Lieutaud  was  the  follower  of  Morgagni,  and  rect^rded  many 
interesting  observations  made  at  the  postmortem  table,  but  his 
work  is  really  nothing  more  than  a  note-book,  unclassified  for  the 
most  part,  and  without  any  deductive  instruction. 

Diphtheria. — Besides  laryngeal  and  tracheal  polypi  and  ulceration 
of  the  larynx,  we  find-  this  remark  on  the  pathological  conditions 
in  the  air  passages  of  a  girl  CNidently  dead  of  dii)litlieria:  "  Glottidi 
haerebat  materia  quaedem  mucosa.  Interior  tracheae  facies  crusta 
viscida  purulenta  investiebatur,"  etc.  There  are  records  of  other 
cases  of  a  like  nature.  He  observed  pus  in  tlie  frontal  and  occipital 
(sic)  sinuses.^ 

THE  NINETEENTH  CENTURY— THE  PRE-LARYNGOSCOPIC 

ERA. 

I  do  not  know  how  I  can  better  usher  in  our  story  of  a  new  epoch 
than  by  going  back  into  the  eighteenth  century  to  pick  up  the 
thread  of  the  ideas  which  have  dominated  the  latter  part  of  the 
nineteenth.  This  I  shall  frequently  have  to  do  in  matters  more 
immediately  cognate  with  our  subject. 

The  Intermaxillary  Bone  in  Man. — In  1779  Vicq  D'Azir^ 
announced,  before  the  Academy  of  Science  in  Paris,  that  he  had 
been  able  to  trace  the  intermaxillary  bone  in  the  human  f(etus, 
and  he  had  Darwinism  in  his  mind  when  he  made  the  refiection 
that  Nature  seems  always  to  model  her  works  after  a  primiti\'e 
ideal.  In  1784  Goethe  wrote  to  his  friend  Herder:  "I  have  found 
neither  gold  nor  silver,  but  that  which  gives  me  an  inexpressible 
delight,  the  os  intermaxillare  in  man."  This  had  been,  api)arently 
by  an  accidental  blunder,  as  we  have  seen,  described  by  Galen 
and  depicted  by  many  of  the  anatomists  of  the  Renaissance.  This 
had  been,  if  we  may  be  allowed  the  expression,  a  bone  of  contention 
for  many  centuries.  The  fact  that  man  was  supposed  to  have 
no  intermaxillary  bone  was  one  of  the  arguments  by  which  he 
was  distinguished  from  the  brutes,  but  Goethe  believed  in  the 
unity  of  nature,  and  six  years  later  he  wrote  his  "Metamorphose 
der  Pflanzen,"  in  which  is  contained  the  philosophy  of  Spencer 
and  the  biology  of  Darwin. 

And  now  we  must  plunge  at  once  into  the  medical  history  of 
the  nineteenth  century,  returning,  as  1  have  said,  many  times  to 
pick  up  the  threads  of  our  story  amidst  the  records  of  past  ages. 

1  Lib.  II,  Ep.  XIX,  p.  54. 

2  Hist.  Anatom.  Med.,  Parisiis,  17G7,  I,  p.  435.  ^  jbij    u^  p    292. 
*  Oeuvres  de  Vicq  D'Azir,  Paris,  1805,  IV,  p.  1.59. 


BICHAT  179 

It  is  still  impossible  to  comprehend  the  historical  significance  of 
the  phenomena  of  the  nineteenth  centnry  just  passed.  We  are 
just  leaving  it  behind,  and  its  proximity  in  the  historical  landscape 
gives  us  no  opportunity  for  philosophical  perspective,  while  the 
lifeless  chronicle  of  events  is  a  dreary  work  which  is  to  be  avoided 
if  possible. 

Bichat. — The  French  Revolution,  the  great  cataclysm  which 
finally  and  irrevocably  burst  asunder  the  bands  of  ecclesiastical 
and  political  tyranny,  horrible  and  frightful  as  was  the  catastrophe 
and  its  immediate  results,  was  the  denouement  of  that  series  of 
events  to  which  the  Renaissance  was  the  prelude  in  the  history  of 
civilization.  In  the  Sciences,  and  especially  in  ^Medicine,  the 
beginning  of  the  fruition  of  this  enfranchisement  of  thought,  of 
speech,  and  action  did  not  become  apparent  until  near  the  middle 
of  the  century  just  passed.  Coincident  with  the  social  and  political 
upheaval  in  France  appeared  the  genius  which  shaped  the  beginning 
of  the  new  life  in  ^Medicine  as  radically  as  did  Xapoleon  those 
events,  the  chronicling  of  which  is  called  History. 

Bichat  was  the  first  to  turn  the  torrent  of  eager  study  and  in^'esti- 
gation  of  biological  secrets  toward  the  elucidation  of  the  physiology 
and  pathology  of  the  separate  tissues,  as  distinguished  from  the 
anatomical  localities  and  organs  of  the  animal  body.  Before 
Bichat,  since  the  time  of  the  Arabs,  diseases  were  divided  according 
to  their  situation,  the  head,  the  chest,  the  stomach.  ]\Iorgagni  first 
classified  disease  according  to  the  lesions  of  the  difterent  organs 
of  the  body.  Bichat,  continuing  the  differentiation,  described  the 
different  tissues  of  which  the  various  organs  were  made  up. 

Since  the  revolt  of  Cullen  and  his  predecessors  from  the  old 
humoral  patholog,y,  we  have  been  practically  upon  a  basis  of  the 
Solidism  which  he  had  carried  to  such  extremes.  It  is  only  within 
the  last  few  decades  that  we  have  begun  to  perceive  that  all  such 
divisions  are  impossible,  all  regions,  all  organs,  all  tissues,  all  of 
the  body  fluids  are  too  intimately  associated,  one  with  the  other, 
to  allow  us  to  single  out,  in  disease,  any  single  unit  as  the  entity 
exclusively  deranged;  but  we  may  note  a  tendency  in  the  recent 
trend  of  research  in  the  problems  of  immunity  for  the  pendulum 
to  swing  back  again,  after  nearly  two  hundred  years,  to  the  domains 
of  humoral  physiology  and  pathology. 

Bichat  sketched  the  outlines  of  the  study  of  physiology  and 
pathology  which  were  later  filled  out  by  the  labors  of  the  Germans, 
the  schools  of  Johann  ^Nliiller,  and  of  Virchow. 

In  his  "Anatomic  Pathologique"  he  considered  the  functions 
and  the  morbid  states  of  the  serous  and  of  the  pituitary  membranes, 
but  he  insisted^  that  not  only  should  pathology  be  studied  from  the 

'  An;itoinio  Pathologique.  Dernier  Cours  de  Xavier  Bichat  d'apres  un 
Manuscrit  Autographe  de  P.  A.  Bcclard — 1825. 


180  THE  PRE-LARYNGOSCOPIC  ERA 

standpoint  of  the  system  of  tissues  affected,  hut  from  that  of  the 
character  of  the  lesion  as  welL  It  is  true,  here  as  always,  that  this 
thought  had  existed  in  the  minds  of  many  before  Bichat,  but  it 
was  left  to  him  to  inaugurate  its  practical  application.  He,  himself, 
had  little  opportunity  in  his  short  life  to  even  begin  the  Herculean 
task  of  filling  out  this  comprehensive  schedule.  He  died  when  just 
turned  thirty. 

Special  Treatises. — Before  reviewing  the  comparatively  few 
steps  in  advance  taken  in  the  knowledge  of  our  subject  during  the 
pre-laryngoscopic  era  of  the  nineteenth  century,  some  reference 
must  be  made  to  special  treatises. 

Olfaction. — In  the  early  part  of  the  century  considerable  attention 
was  devoted  to  the  nose  as  the  organ  of  olfaction.  Indeed,  since  the 
decline  of  the  Galenic  physiology  and  the  establishment  of  the 
doctrines  of  Schneider,  the  fact  has  often  been  lost  sight  of  alto- 
gether that  the  nostrils  were  an  essential  part  of  the  respiratory 
tract.  AYhen  it  l)ecame  evident  that  the  air  did  not  ascend  to  the 
brain,  and  the  secretions  of  the  latter  did  not  drip  downward  in 
catarrh,  the  warming,  dust  freeing,  moistening  functions  of  the 
nose  in  respiration,  upon  which  Galen  laid  the  proper  stress,  sank 
from  view  and  have  only  again  been  brought  into  prominence 
within  in  the  last  three  decades. 

Jacobson's  Organ. — We  have  seen  that  the  mistaken  idea  of 
some  of  the  early  anatomists,  as  to  the  olfactory  function  of  the 
accessor}'  sinuses,  long  lingered  after  the  error  had  been  pointed 
out  that  they  prepared  the  air  for  the  brain.  This  idea  of  the  nose 
solely  as  the  organ  of  smell  probably  led  to  the  prompt  acceptation 
of  the  organ  of  Jacobson  as  an  occasional  diverticulum  in  the  mucosa 
ser\ing  for  olfaction.  The  great  Guxier  laid  the  Danish  anatomists's 
communication^  before  the  Institute  of  Paris  in  1811.  Kuysch,- 
in  1703,  pictured  the  orifice  in  the  nose  of  an  infant  he  had  dissected. 
INIorgagni''  refers  to  Steno  as  having  noted  this  organ  in  a  sheep. 
He  seemed  to  connect  it  in  some  way  with  cases  which  Thomson 
(1.  c.)  rightly  regards  as  instances  of  the  escape  of  the  cerebro- 
spinal fluid  from  the  nose.  Sommering  also  noted  it  before 
Jacobson's  paper.^ 

Deschamps. — Deschamps,'^  in  1804,  published  the  first  separate 
"Treatise  on  the  Diseases  of  the  Nasal  Fossic  and  Their  Sinuses." 
Naturally  prominence  was  given  to  the  physiology  and  i)ath()logy 
of  olfaction,  and  Deschamps  declared  that  the  filaments  of  the 

1  Desoriptive  Anat.  d'nn  oi<?:in  observe  'dans  les  MammifSres.  Ann.  de 
I'Inst.  d'llist.  Nat.,  XVIII,  ISU,  p.  412-24. 

2  Ruysch:   Thesaur.  Anat.,  Amst.,  1744,  III.,  Tab.  IV,  fig.  5,  A. 

'  Morgagni:  Dc  sodibus  et  Causis  Moiboriim,  Lib.  I,  Do  ]\Iorbis  Capitis, 
21. 

■*  For  further  information  as  to  llie  lii.story  of  the  organ  sec  Mihalkovics. 
Nasenliohle  und  Jaeobsonsches  Oi'gaii,  Wiesbaden,  1S98. 

*  Traits  des  Maladies  des  Fosses  Nasales,  Paris,  1804. 


DESCHAMPS  181 

olfactory  nerve  mav  easily  be  traced  to  the  middle  of  the  nasal 
fossae,  but  he  denied  absolutely,  as  a  result  of  experimentation, 
that  the  sinuses  contribute  anything  toward  the  function  of  olfac- 
tion. This  had  been  previously  less  emphatically  asserted  by 
Richeraud.^  Notwithstanding  these  positive  statements,  such 
eminent  authority'  as  Magendie  in  1817  inclined  to  the  opposite 
opinion.  He  says:  ''The  larger  size  of  the  sinuses  seems  to  coincide 
with  a  greater  power  of  olfaction;  this  at  least  is  one  of  the  most 
positive  results  of  comparative  anatomy."  He,  however,  admitted 
that  the  olfactory  filaments  had  never  been  followed  into  the 
sinuses  nor  found  in  the  mucosa  of  the  inferior  turbinated  bone, 
nor  on  the  inner  surface  of  the  middle. 

Deschamps'  work  of  more  than  300  pages  is  one  of  considerable 
interest,  not  only  because  it  was  the  first  separate  book  on  Rhin- 
ology,  but  because  it  may  be  supposed  to  represent  fairly  well  the 
state  of  knowledge  at  the  beginning  of  the  century  as  to  intranasal 
disease.  He  says  nothing  Avhatever  of  anterior  rhinoscopy,  nor 
of  a  nasal  speculum,  though,  as  we  have  seen,  traces  of  both  had 
from  time  to  time  appeared  in  medical  annals.  Notwithstanding 
this  most  important  and  other  scarcely  less  noticeable  omissions, 
he  professed  to  include  all  the  matter  of  interest  known  to  medicine 
in  regard  to  the  nasal  fossffi  and  their  annexa  in  his  book.  He 
distinguished  the  ordinary  tumefaction  of  the  mucosa  from  the 
nasal  polyp,  and  for  the  former  he  recommended  the  use  of  oiled 
bougies  in  dilating  the  obstructed  channels  of  the  nose.  He  divided 
nasal  polypi  into  (1)  fungous  and  vascular.  (2)  Mucous  and 
lymphatic.  (3)  Scirrhous.  (6)  Sarcomatous.  His  methods  of 
treatment  were:  (1)  The  local  application  of  astringents.  (2) 
Excision  with  a  guarded  bistouri.  (3)  Avulsion  with  the  forceps, 
to  which  he  devotes  considerable  sj^ace.  (4)  The  knotted  thread 
he  speaks  of  with  ridicule.  (5)  Chemical  caustics,  nitrate  of  silver 
— "mercurial  water"  (acid  nitrate?) — butter  of  liquid  antimony, 
and  the  actual  cautery.  (6)  Ligature  with  a  waxed  thread  and 
with  wire  of  pure  silver. 

These  methods  of  operating  he  adapted  to  his  different  varieties 
of  polypi,  giving  preference  to  the  ligature.  The  wire  loop  adjusted 
with  forceps  and  finger  was,  when  in  situ,  tightened  by  pulling  it 
through  the  eye  of  a  probe  or  sound.  The  polyj)  was  removed 
more  by  avulsion  than  by  abscission.  For  oztena,  he  recommended 
the  application  of  the  cautery  when  "  the  site  of  the  ozajna  permits;" 
otherwise  he  abandoned  the  treatment  of  this  disease  to  jialliative 
measures.  He  confused  essential  oztena  with  the  syphilitic.  Con- 
siderable space  in  this  book  is  devoted  to  the  consideration  of 
sinus  disease,  principally  of  the  maxillary  antrum,  but  he  recognized 
the  painful  symptoms  of  acute  catarrhal  inflammation  of  the  frontal 
sinus.     He  speaks  of  simple  inflammation  of  the  maxillary  sinus, 

^  Nouveaux  Elements  de  Physiologie,  2  ed.,  Paris,  1802,  Vol.  II,  p.  57. 


182  THE  PRE-LARYNGOSCOPIC  ERA 

also  of  polypous  tumors,  and  of  dropsy  of  that  cavit3^  He  counsels 
opening  the  maxillary  sinus,  in  su})i)urative  disease,  through  an 
alveolus  of  a  bad  tooth  if  it  exists;  otherwise  to  make  an  opening 
above  the  alveolar  border,  in  either  case,  large  enough  to  introduce 
the  finger.  He  advised  an  even  larger  opening  where  there  were 
antral  polypi.  He  has  nothing  to  say  of  ecchondroses  or  deviations 
of  the  nasal  septum. 

Cloquet. — A  very  much  more  comprehensive  work,  especially  in 
historical  matters,  was  the  work  of  Cloquet,^  which  was  first 
published  in  1821.  It  professes  to  be  a  work  on  olfaction,  but  as 
a  matter  of  fact  it  is  much  more  than  that.  Its  750  pages  exhibit 
the  enormous  erudition  of  the  author,  who  deals  with  his  subject 
in  the  most  exhaustive  manner  and  from  every  point  of  view.  It 
is  an  inexhaustible  source,  from  which  one  may  draw  accounts 
of  all  sorts  of  phenomena  related  to  the  sense  of  smell.  Not  only 
is  this  its  prominent  characteristic,  but  it  deals  incidentally,  much 
more  fully  than  Deschamps'  book,  with  the  nose  and  its  diseases. 
Membranous  occlusions  of  the  nostrils,  fractures  of  the  nose, 
deviations  of  the  septum  which  he  considered  to  be  usually  irreme- 
diable, rhinoplasty,  are  all  more  or  less  thoroughly  discussed. 
Coryza,  vasomotor  rhinitis,  rhinorrhoea,  and  syphilitic  rhinitis, 
with  other  afi'ections,  are  treated  together,  and  not  sufficiently 
difi'erentiated  to  satisfy  the  modern  reader.  The  same  may  be 
said  of  other  chapters  in  the  book.  Thickenings  of  the  nasal 
mucosa  are  considered  in  a  page  and  a  half. 

Watt. — These  works  of  Deschamps  and  Cloquet  were  not  illus- 
trated, but  we  may  note  in  England  the  appearance  in  1809  of 
the  "  Anatomico-Chirurgical  Views  of  the  Nose,  JMouth,  Larynx, 
and  Fauces,"  by  John  James  \Yatt.  It  contains  some  colored  charts 
of  the  parts  with  an  anatomical  description  of  them.  They  compare 
not  unfavorably  as  to  accuracy,  but  are  i)erhaps  not  so  artistic 
as  the  later  color  plates  which  have  been  issued  so  frequently 
lately.  They  are  the  first  colored  plates  with  which  I  am  familiar 
showing  the  anatomy  of  the  nose  and  throat. 

Porter. — A  few  separate  treatises  appeared  in  the  pre-laryn- 
goscopic  period  on  the  larynx.  In  1826  William  Henry  Porter 
published  a  small  brochure  in  which  he  discussed  croup,  diphtheritis, 
oedematous  laryngitis,  phthisis  laryngea,  which  he,  like  others, 
confused  with  syphilis  of  the  air  tubes,  speaking  at  some  length  of 
the  "mortification  of  the  laryngeal  cartilages."  Traumatic  laryn- 
gitis, foreign  bodies,  and  wounds  are  also  discussed.^     It  is  not 

^  Osphrcsiologie. 

^  Observations  on  tlie  Surgical  Pathology  of  the  Larynx  and  Trachea, 
2  ed.,  London,  1837.  1  am  only  familiar  with  the  second  edition.  Holmes 
speaks  of  the  first  edition  as  too  limited  in  scope  to  be  compared  with  the 
treatise  of  Albers,  which  appeared  in  1829.  However  that  may  be,  it  is  the 
first  separate  treatise  on  the  larynx  since  the  little  work  of  Codronicus,  two 
and  a  half  centuries  earlier. 


PIORRY  183 

accurate,  therefore,  to  regard  Albers'  work  as  the  first  special  work 
on  the  larvnx. 

Albers. — It  appeared  in  1829.^  As  Heyman  has  pointed  out,  it 
is  a  work  of  considerable  value  in  that  it  collected  what  was  known 
on  the  subject,  but  it  is  by  no  means  exhaustive  in  that  respect, 
and  there  is  very  little  original  matter  in  it.  Of  more  value  are 
the  chapters  he  devotes  to  the  subject  in  his  later  publication.^ 
In  his  Atlas  there  are  some  striking  drawings  of  laryngeal  tumors. 
In  other  respects  the  works  of  Albers  are  noteworthy  as  almost 
the  beginning  of  those  publications  on  pathological  subjects 
which  were  soon  to  make  the  medical  schools  of  Germany  famous. 

Ryland  and  Colombat.— In  1838  appeared  the  works  of  Ryland^ 
and  of  Colombat.^  Ryland  speaks  of  croup  as  affecting  children 
and  of  the  Diphtheria  of  Bretonneau  as  affecting  adults.  He  refers 
also  to  spasmodic  croup  and  hysterical  spasm  of  the  glottis,  cases 
having  been  reported  by  Albers,  Sir  Charles  Bell,  and  Porter. 
Tumors  of  the  larynx  and  tracheotomy  occupy  considerable  space 
in  his  book.  Colombat  invented  a  clumsy  instrument  for  opening 
the  mouth  and  depressing  the  tongue,  which  he  called  a  stomato- 
scope,  also  some  devices  of  inferior  interest  for  cutting  the  tonsils 
and  the  uvula. 

Piorry. — A  very  much  more  interesting  work,  and  one  evincing 
more  original  though  frequently  erroneous  ideas,  is  the  one  by 
Piorry  published  in  1844.^  He  opens  his  work  with  the  remark 
that  the  diseases  of  the  nose  are  unfortunately  usually  not  considered 
in  treatises  on  diseases  of  the  respiratory  system,  and  he  insists 
on  the  doctrine,  which  received  no  help  e\en  from  the  ad^-ent  of 
laryngoscopy,  that  not  only  many  diseases  of  the  larynx  but  also 
of  the  lungs  depend  upon  morbid  conditions  of  the  nasal  passages, 
nasal  obstruction,  called  by  him  rhinostenoma,  one  of  the  forms 
of  which  we  recognize  in  a  deviated  septum,  the  other  being  alter- 
nating vasomotor  stenosis.  He  proposed  percussion,  then  a  young 
science,  for  investigating  the  accessory  sinuses.  He  described  with 
considerable  accuracy  many  of  the  sequelae  of  nasal  obstruction 
and  mouth  breathing,  including  aural  symptoms  from  closure  of 
the  Eustachian  tube,  and  pulmonary  changes,  such  as  chronic 
dyspnoea  and  asthmatic  attacks.  He  referred  the  cause  of  nasal 
disease  to  systemic  affections.  Crusts  in  the  nose  are  to  be  removed 
after  soaking  in  oil. 

1  Die  Pathologie  und  Therapie  der  Kelilkopfskrankheitcn.     Leipzig,  1829. 

-  Beobachtungen  a.  d.  Gebiet.  der  Path.,  Bonn,  1S3G.  Atlas  der  path. 
Anat.,  2te  Abth.,  Bonn,  1842. 

'  A  treatise  on  the  Disea.ses  and  Injuries  of  tlic  Larynx  and  Trachea,  by 
Frederick  Ryland.     London,  1837. 

^  Traite  des  Maladies  et  de  la  Hj-gienc  de  la  Voix.     Paris,  1838. 

*  Ueber  die  Krankheiten  der  Luftwegc,  von  A.  Piorry.  Leipzig,  1844. 
It  seems  to  have  been  written  but  never  published  in  French,  the  German 
edition  being  the  only  one  I  have  found  noted. 


184  77//?   PRE-LARYNGOSCOPIC  ERA 

Nasal  Bougies. — Piorry  advised  the  introduction  of  bougies  even 
in  acute  attacks.  He  described  the  dilatation  of  the  alae  nasi  with 
a  forceps  to  allow  the  light  to  fall  in,  but  achnittcd  that  it  was 
im})0ssible  to  see  very  far  by  this  means.  StctIiosco])y  was  also 
recommended  by  him  in  the  diagnosis  of  intranasal  conditions.  He 
described  rhinitis  attending  cases  of  the  grip,  which  was  prevalent 
in  the  fir.st  half  of  the  century.  On  the  whole  this  book  exhibits 
a  surprising  amount  of  information  in  regard  to  intranasal  conditions 
at  an  epoch  when  anterior  rhinoscopy  was  feebly  developed,  and 
posterior  rhinoscopy  was  unknown.  Some  of  his  ideas  have  not 
received  the  sanction  of  modern  rhinology,  but  may  not  on  that 
account  be  the  less  true.  He  declared  that  one  of  the  causes  of 
rhinitis  was  the  cutting  of  the  vibrissse  in  the  vestibule  of  the  nose 
which  should  filter  the  dust  particles  from  the  air. 

Evil  Effects  of  Water  on  the  Nasal  Mucosa. — Piorry  asserted  that 
water  was  injurious  to  the  whole  upper  respiratory  tract  with  the 
exception  of  the  nasopharynx,  and  syringing  either  the  ear  or  the 
nose,  especially  with  cold  water,  resulted  in  inflammation.  Rhinitis 
thus  frequently  arose  from  bathing  and  diving.  As  treatment  he 
urged  the  injection  of  oily  or  fatty  substances  in  the  nose.  To 
such  extremes  did  he  go  in  this  direction  that  he  advised  the  annoint- 
ing  of  the  nostrils  with  oil  while  shaving  or  washing  the  face.  The 
intranasal  syringing  of  water  he  condemned  very  strongly  except 
for  the  purpose  of  removing  foul,  stinking  secretions.  Nitrate 
of  silver  and  various  powders  he  recommended  as  medicaments  for 
internal  aj)j)lications.  His  other  therapeutic  measures  were  of  a 
general  nature,  in  accordance  with  his  views  of  etiology.  Blisters, 
bleeding,  purging,  sweating,  were  the  vigorous  measures  which 
were  recommended  for  rhinitis,  in  keeping  with  the  heroic  treat- 
ment of  his  times.  He  confused  ozaena  with  ])urulent  disease  of 
the  accessory  cavities.  For  intranasal  operative  procedures  he 
refers  the  reader  to  the  general  works  on  surgery.  His  remarks 
upon  affections  of  the  larynx,  trachea,  and  bronchi,  as  one  must 
expect  in  pre-laryngoscopic  times,  are  confusing  and  of  little  value. 

Systems. — In  the  first  half  of  the  nineteenth  century  began  again 
the  custom  of  including  in  one  work,  or  in  a  continuous  series,  all 
the  medical  lore  known  to  mankind,  but  instead  of  such  a  work 
being  attempted  by  one  author  it  was  divided  among  several.  In 
these  early  Systems  and  llaudbuchs  and  Traites  the  chapters  on 
the  nose  and  throat  are  lacking,  or  treated  in  the  most  cursory 
and  incomi)lete  manner.  As  an  example  of  this  sort  of  literature 
one  may  be  cited  ^^herein  the  following  was  published,  just  three 
years  before  Garcia  announced  the  event,  which  at  once  shed  a  new 
light  on  diseases  of  the  larynx. 

Friedreich"^  says:      "Unfortunately   the    methods    of    physical 

'  Die  Krankhoitcn  des  Larynx  und  der  Trachea,  Virchow's  Handbuoh 
der  spec.  Path,  und  Therapie,  1858,  Vol  I,  p.  417. 


BRETON NEAU  AND  DIPHTHERIA  185 

diagnosis  do  not  allow,  in  diseases  of  the  larynx  and  trachea,  that 
extended  application  they  do  in  diseases  of  the  deeper  parts  of  the 
respiratory  organ." 

Laennec's  "Traite  de  I'Auscultation  ^Mediate"  in  1819,  his 
in^'ention  of  the  stethoscope,  and  the  rapid  (le\'elopment  of  the 
other  methods  of  the  physical  diagnosis  of  the  diseases  of  the  chest, 
doubtless  did  their  part  in  stimulating  interest  and  curiosity, 
which  finally  culminated  in  the  application  of  inspection  to  the 
diagnosis  of  intralaryngeal  lesions. 

Auscultation  and  Percussion  of  the  Nose  and  Throat. — ^^e  ha\'e 
noted  Piorry  attempting  to  apply  Laennec's  methods  to  diseases 
of  the  nose,  and  we  find  Friedreich  attempting  to  explore  laryngeal 
phenomena  by  means  of  palpation,  auscultation,  and  inspection 
of  the  epiglottis  through  the  mouth.  In  Friedreich's  chapters  we 
find  intelligent  attempts  at  differentiating  tubercular  from  syphilitic 
diseases  of  the  larynx,  but  oedema  of  the  glottis  and  perichondritis 
laryngea  are  for  him,  as  for  many  later  writers,  still  pathological 
entities.  He  speaks  of  paralysis  of  the  glottis  with  aphonia  as 
paraplegias,  but  of  course  he  had  no  means  of  establishing  a 
diagnosis  except  from  rational  symptoms. 

To  return  now  to  the  individual  topics  of  interest  in  the  develop- 
ment of  our  laryngological  and  rhinological  knowledge,  we  may 
begin  again  with  Bichat. 

In  the  few  notes  which  remain  to  us  from  the  Avorks  of  Bichat 
upon  the  histology  of  the  diseases  of  the  pituitary  membranes,  he 
cast  but  little  light  upon  the  subject.  We  may  note,  however,  that 
he  questioned  whether  ozsena  was  really  an  ulceration,  but  leaned 
to  the  idea  that  it  was  a  diffuse  inflammation.  He  speaks^  of  the 
liability  of  the  mucous  membrane  of  the  larynx  to  become  gorged 
with  serum  during  inflammation.  He  succeeded  by  traumatism 
in  producing  this  condition  in  dogs,  but  we  look  in  vain  for  those 
details  of  the  study  of  the  respiratory  mucous  membranes,  which 
later  followed,  from  Bichat's  initiative,  in  the  works  of  Bretonneau 
and  others. 

In  1791  Fourcroy  and  Vauquelin  had-  examined  nasal  secretions, 
both  in  healthy  sul)jects  and  in  those  suftering  from  coryza,  and 
had  noted  the  salts  of  lime  and  soda.  According  to  him,  the  nuicus 
was  the  same  from  all  the  mucous  membranes,  but  Berzelius  later, 
on  the  contrarv,  believed  it  to  var\-  according  to  the  locality  from 
which  it  was  taken.  ]\Iagendie  thought  that  the  mucous  glands 
are  not  necessary  for  its  formation,  but  that  it  is  found  where  there 
are  none,  and  also  after  death. 

Bretonneau  and  Diphtheria. — These  were  some  of  the  preliminary 
studies  which,  together  with  the  direction  given  to  medical  study 
by  Bichat,  lead  to  Bretonneau's  "Treatise  on  Diphtheria."     In  tlic 

'  Traite  d'Anatomie  Dcscript  ivp,  Paris,  1802,  II,  p.  399. 
2  Annales  dc  Chimic.  Aout,  1791,  Vol.  X,  p.  13. 


186  THE  PRE-LARYNGOSCOPIC  ERA 

works  of  Matthew  Baillie,  which,  though  not  collected  until  1825, 
were  of  a  considerably  earlier  date,  may  be  found  several  accurate 
accounts  of  the  postmortem  appearances  in  those  dead  of  Croup. ^ 

Anglada  says:  "It  is  known  that  Napoleon,  in  1S07,  on  account 
of  a  sorrowful  event,  put  the  question  of  Croup  to  the  Assembly; 
numerous  and  important  works  followed."  He  offered  a  prize  for 
the  best  essay  on  the  disease,  owing,  it  is  said,  to  the  death  of  a 
son^  from  it.  Not  only  in  France,  but  elsewhere,  as  we  have  seen, 
the  disease  was  being  more  carefully  studied.  John  Cheyne,  in 
1809,  wrote  on  "The  Pathology  of  the  ]\Iembrane  of  the  Larynx 
and  Bronchi,"  a  treatise  which  is  chiefly  upon  the  lesions  of  Croup, 
under  which  title  he  also  published  a  work. 

It  was  not,  however,  until  Bretonneau's  publication,  in  1826,' 
that  any  very  great  advance  is  to  be  noted  in  the  nineteenth  century 
in  the  study  of  diphtheria.  He  recognized  its  specific  character 
and  thus  gave  it  its  name  (p.  41-43):  "From  the  impossibility 
of  applying  to  a  special  inflammation,  so  Avell  defined,  a  single  one 
of  the  names  which  have  been  given  to  its  variations,  allow  me  to 
designate  this  phlegmasia  by  the  name  Diphtheritis,  derived  from 
dciffiiijo.,  which  means  a  skin,  an  exuvium." 

His  work  gives  by  far  the  best  description  of  the  disease  which 
had  3'et  appeared,  but  even  in  its  clinical  manifestations  the  differ- 
entiation was  much  at  fault.  In  addition  to  his  own  remarks  on 
the  disease,  he  transcribed  the  works  of  many  previous  writers, 
among  them  that  of  Samuel  Bard.  He  had  performed  tracheotomy 
for  the  laryngeal  disease,  and  was  of  the  opinion  that  his  was  the 
first  case  in  which  it  was  successfully  done,  though  he  refers  to  the 
case  in  London  reported  by  Borsieri,  which  I  have  cited.  Breton- 
neau's work  produced  a  great  imjjression  upon  his  contemporaries, 
and  it  is  one  of  the  landmarks  in  the  history  of  diseases  of  the 
throat.  Shortly  after  its  publication,  we  may  note  the  report  of  a 
fatal  case  of  nasal  diphtheria  by  Billard,''  but  he  does  not  give  it 
that  name. 

The  Epiglottis. — Bichat,^  from  experimentation,  had  come  to  the 
conclusion  that  the  epiglottis  was  in  no  way  essential  to  the  produc- 

^  See  also  The  Morbid  Anatomy  of  Some  of  the  Most  Important  Parts  of 
the  Human  Body,  London,  179:3,  and  A  Series  of  Engravings,  etc.,  London, 
1800,  in.     PhUe  II,  Fig.  1. 

The  word  Croup,  first  used  by  Home,  is  of  Scottish  origin,  designating  a 
membranous  inflammation  of  the  air  passages,  and  is  said  to  have  primaril}'- 
signified  strangulation,  but  it  is  from  a  Gothic  root,  meaning  to  cry  out,  the 
term  being  applied  to  the  disease  probably  on  account  of  the  altered  tone 
of  the  voice. 

^  If  tliis  is  so,  it  must  have  been  an  illegitimate  son.  Constant  in  his 
Memoirs  of  the  Private  Life  of  Napoleon,  mentions  no  such  event  as  the  death 
of  an  illegitimate  child  at  this  time. 

'  Des  Inflammations     .     .     .     et     .      .     .     de  la  Diphth6rite,  1826. 

*  Traite  des  Maladies  des  Enfants,  1828.  I  have  seen  onlj-  the  second 
edition,  1S.3;1 

*  Trait6  de  1' Anatomic  Descriptive,  Paris,  1802. 


INNERVATION  OF  THE  LARYNX  187 

tioii  of  the  voice,  which,  however,  was  altered  when  he  cut  off  the 
tops  of  the  arytenoid  cartilages,  and  was  lost  when  he  severed  them 
from  one  another  in  the  middle  line.  We  have  seen  how  gross  an 
error  had  entered  into  the  conception  of  the  ancients  in  supposing 
the  epiglottis  served  to  keep  solids  from  the  larynx,  but  permitted 
fluids  to  enter  it.  It  gradually  was  accepted  as  an  efficient  valve 
to  keep  the  latter  out  also.  iMagendie  refused  to  accept  this  on 
authority.  He  said^  he  himself  was  of  the  former  opinion,  except 
for  the  doubt  that  should  always  exist  in  the  mind  of  the  physi- 
ologist. On  extirpating  the  epiglottis  in  dogs  he  found  they 
swallowed  fluids  as  well  as  solids  quite  as  easily  without  it.  Else- 
where^ he  asserts  he  had  observed  the  same  phenomenon  in  two 
individuals  deprived  of  the  epiglottis  by  disease.  He,  therefore, 
concluded  that  it  was  not  indispensable  in  deglutition.  From 
various  experiments  on  animals  he  did  much  not  only  to  elucidate 
the  mechanism  of  swallowing,  but  the  action  of  the  intralaryngeal 
muscles  as  well,  though  his  conclusions  have  not  been  all  of  them 
confirmed  by  later  investigations.  One  notes  the  significance  of 
the  new  order  of  things  in  France  at  this  time  in  the  field  of  medicine 
as  well  as  in  all  other  subdivisions  of  science. 

Innervation  of  the  Larynx. — Le  Gallois,^  in  1812,  inaugurated  a 
series  of  investigations  as  to  the  innervation  of  the  larynx,  to 
which  later  writers  have  not  since  added  so  large  a  number  of  well- 
ascertained  facts  as  we  might  expect  from  ad^•ances  in  other  fields 
of  physiological  research. 

Dupuytren  and  Bichat  had  both  obser\'ed  the  efi'ect  of  cutting 
the  pneumogastric,  and  many,  since  Galen's  account,  had  noted 
the  results  of  section  of  the  recurrent  laryngeal  nerves;  but  it 
remained  for  Le  Gallois  to  demonstrate  that  death,  which  so  often 
supervenes,  especially  in  young  dogs,  when  the  pneumogastrics 
are  cut,  was  due  to  section  of  the  recurrent  fibers  in  it,  and  that 
this  also  happened  when  both  recurrents  were  simultaneously  cut. 
He  noted  this  happened  less  suddenly  the  older  the  dogs  were. 
He  found  that  the  glottic  aperture  was  more  narrowed  by  the 
operation  in  young  than  in  old  dogs.  He  also  drew  attention  to 
the  varying  effects  from  ligation  of  the  recurrents,  due  to  the 
degr(ies  of  pressure  exerted.  Le  Gallois  did  not  take  so  much  pains 
to  record  the  color  and  sex  of  the  dogs  in  his  experiments,  but  on 
the  j)erusal  of  his  work  it  may  easily  be  seen  how  much  of  the  work 
of  more  recent,  more  voluminous,  and  less  readable  experimenters 
was  anticipated  by  him. 

Sir  Charles  Bell,^  in  1(S21,  asserted  that  because  the  vagus  nerve 
does  not  arise  by  a  double  root  and  has  no  ganglia  it  is  not  a  nerve 

1  Mcmoire  sur  rp'.piglotto,  Paris,  1S13. 

-  Precis  Elementaire  de  Phj'siologie,  Paris,  1817,  \'ol.  II,  p.  63. 
^  Le  Gallois:  Exporicncos  sur  le  Prineipe  de  la  \'ie,  Paris,  1S12. 
*  On  the  Nerves.     Phil.  Trans.,  London,  1821,  ]).  398. 


188  THE  PRE-LARY NGOSCOPIC  ERA 

of  sensation,  he  having  shown,  simultaneously  with  ]\Iagendie, 
that  the  posterior  roots  of  the  spinal  nerves  are  sensory  and  the 
anterior  roots  are  motor  filaments.  Another  theory  of  ^Macendie 
was  contradicted  by  Robert  Willis  in  1829,  and  later  by  ("laiide 
Bernard.  They  showed  that  it  was  erroneous  to  regard  the  superior 
laryngeal  nerves  as  supplying  filaments  to  the  closers  of  the  glottis, 
and  the  inferior  laryngeal  nerves  as  sending  branches  exclusively 
to  the  openers  of  the  glottis.  Willis,  according  to  Holmes,  did 
much  to  elucidate  the  actions  of  the  various  intralaryngeal  muscles, 
a  matter  still  involved  in  much  uncertainty.^  IMarshall  Ilall,  in 
183(3,2  and  Dr.  John  Reid,  as  well  as  INIagendie,  contributed  largely 
to  the  development  of  our  knowledge  of  this  intricate  subject. 
Hall  was  apparently  the  first  to  point  out  the  reflex  nature  of 
Spasmodic  Croup.  His  idea  that  it  is  due  to  the  irritation  of  teeth- 
ing, indigestion,  and  constipation  has  been  much  invalidated,  but 
only  in  very  recent  years. 

Sir  Astley  Cooper,  in  drawing  attention  to  his  discovery  of  the 
ganglion  of  the  superior  laryngeal  nerve  in  the  vagus,  opened  the 
way  for  Cock''  and  Hilton^  to  declare  the  internal  branch  was 
exclusively  a  nerve  of  sensation,  the  inferior  or  recurrent  nerve 
being  the  exclusively  motor  nerve  of  the  larynx  and  the  external 
branch  of  the  superior  laryngeal  supplying  the  cricothyroid  muscle. 
Dr.  John  Reid^  confirmed  these  conclusions  and  added  many  new 
facts  by  his  investigations  upon  the  glossopharyngeal  and  vagus 
nerves. 

Magendie  was  of  the  opinion  that  section  of  the  superior  laryn- 
geal nerve  prevented  the  emission  of  almost  all  acute  sounds, 
but  Longet,^  who  prefaces  his  account  with  an  exhaustive  bibli- 
ography of  the  work  of  previous  observers,  declared,  as  had  Bischoff 
before  him,  that  the  section  of  this  nerve  produces  no  effect  upon 
the  voice  in  dogs.  They  also  asserted  that  the  Spinal  Accessory 
is  the  motor  root  of  the  pneumogastric  nerve,  Galen  having  con- 
sidered the  former  a  branch  of  the  latter.  The^■  cut  the  Accessorv 
filaments  within  the  skull  and  obtained  aphonia  and  hoarseness 
in  animals.  Notwithstanding  this,  Claude  Bernard,^  that  material- 
istic philosopher,  who  in  many  ways  exercised  such  a  })ernicious 
influence  on  French  thought  in  the  decades  which  followed  him, 
insisted  that  the  Spinal  Accessory  is  a  motor  nerve  and  the  Vagus 
is  a  mixed  one  at  their  origin,  and  that  they  do  not  bear  the  relation 

1  Some  of  the  statements  ascribed  to  Willis  by  Holmes  had  been  long  pre- 
viously made  bj^  other  observers. 

2  Lectures  on  the  Nervous  System,  and  especially  later  in  1S41  in  his  book, 
Diseases  and  Derangements  of  the  Nervous  System. 

3  Edward  Cock:  Guy's  Hospital  Reports,  London,  1837,  II,  p.  311. 
■*  John  Hilton:  Ibid.,  p.  514. 

5  Edinburgh  Medical  and  Surgical  .Tom-nal,  1838,  Vol.  49,  p.  109. 
^  Anatomic  et  Physiologic  du  Syslcinc  Nerveux,  Paris,  1S42,  II,  p.  271. 
'  Archives  G6n<5rales  de  M^decine,    Paris,  1844,  April,  4,  s(^y.,  IV,  p.  397 
May,  V,  p.  .51. 


INNERVATION  OF  THE  LARYNX  189 

to  one  another  of  the  anterior  and  posterior  roots  of  a  spinal  nerve, 
but  that  the  Spinal  Accessory  is  a  motor  ner\'e  which  regulates 
the  movements  of  the  larynx  and  the  thorax  every  time  these 
organs  are  to  produce  phonation,  and  that  the  Pneumogastric 
regulates  them  in  respiration.  Therefore  the  Spinal  Accessory 
should  be  regarded  rather  as  the  antagonist  than  as  the  coefficient 
of  the  ^'agus,  as  phonation  for  the  moment  suspends  the  act  of 
respiration.  He  confirmed  the  observation  by  Magendie  as  to  the 
lack  of  effect  on  the  voice  of  the  section  of  the  superior  laryngeal 
nerve,  which  lesion  induces  anaesthesia 

Bischof}'^  declares,  in  the  Latin  which  as  used  in  the  early  part 
of  the  last  century  was  almost  as  grotesque  as  that  of  the  thirteenth, 
that  Tiedemann  had  assured  them  that  investigations  on  this  nerve 
would  probably  result  in  his  discovery  of  its  function.  This 
encouraging  admonition  to  industry  has  not  been  entirely  realized 
yet,  but  at  least  the  thesis  Bischoff  upheld  has  been  proved  to  be, 
with  some  modifications,  true,  i.  e.,  that  the  vagus  nerve  is  more  or 
less  the  analogue  of  a  posterior  nerve  root  in  that  it  is  chiefly  made 
up  of  sensitive  fibers  while  the  accessorius  furnishes  motor  fibers 
to  it,  among  them  those  of  the  recurrent  laryngeal.  This  followed 
as  a  postulate  from  Bell's  discovery  of  the  function  of  the  anterior 
and  posterior  roots  of  the  spinal  nerves  and  has  been  firmly  fixed 
in  modern  conception  by  the  de\'elopment  of  phylogenetic  science 
on  its  embryological  side.  It  is  a  direct  oft'spring  of  the  idea  of 
Goethe  and  Oken  and  of  Bischoff's  predecessors  that  the  skull 
bones  of  vertebrates  are  nothing  but  modified  ^■ertebrae.2  While 
this  idea  no  longer  has  credit  either  with  embryologists  or  evolu- 
tionists, it  w^as  in  the  air  in  the  pre-Darwinian  era  and  drew  its 
inspiration  from  the  mass  of  thought  out  of  which  sprang  the 
conception  of  the  instability  of  species. 

Longet^  and  Claude  Bernard,^  the  former  by  galvanization,  the 
latter  by  tearing  it  out,  demonstrated  that  the  accessorius  root 
contains  motor  nerve  filaments  governing  the  laryngeal  muscles. 

In  the  work  of  Onodi"  one  may  find  fairly  well  expressed  the 
modern  view:  "In  mammals  a  separation  of  the  spinal  and  the 
bulbar  parts  and  the  calling  of  the  spinal  part  'accessorius'  is  useful 
from  a  practical  standpoint,"  but  whetlier  we  are  otherwise  justified 
in  eliminating  the  word,  'accessory'  is  not  entirely  clear.  They 
are  still  described  in  our  text  books  as  separate  nerves,  but  the 

1  Bischoff:  Nervi  Accessorii,  Willisii  Anatomia  et  Phvsiologia,  Darmstadt, 
1832. 

-  A  resume  of  the  discussion  which  followed  may  be  found  in  Schech: 
Experimentelle  I'ntersuchungen  tibcn-  die  Funktionen  der  Ncrven  und 
Muskeln  des  Kehlkopfs;  Zeitschrift  fur  Biologic,  1873,  IX,  p.  258. 

'  Longet:  Recherches  experiment elles  sur  les  functions  des  nerfs,  des 
muscles  du  huynx,  etc.,  Paris,  1841. 

''  Claude  Bernard:  Lemons  sur  la  physiologie,  et  la  pathologic  du  systeme 
Nerveux,  Paris,  1858,  T.  II. 

*  Onodi:  Anatomie  und  Physiologie  der  Kehlkopfnervcn,  Berlin,  1902. 


190  THE  PRE-LARYNGOSCOPIC  ERA 

consensus  of  opinion  seems  to  he  that  they  helono;  in  the  same 
complex  group,  and  indeed  the  tendency  still  exists  to  place  the 
glossopharyngeal  and  the  hypoglossal  nerves  in  the  same  phylo- 
genetic  group. 

Voice  Production. — The  history  of  the  advance  in  the  knowledge 
of  the  innervation,  and  of  the  kinetic  phenomena  of  the  larynx, 
is  intimately  associated  with  that  of  voice  production.  It  therefore 
seems  best  that  some  account  of  it  shoultl  be  given  here,  though 
this  must  be  done  in  the  most  cursory  way.  Full  accounts  of  the 
progress  of  such  knowledge  may  be  readily  found  in  the  separate 
treatises  of  Gordon  Holmes,^  of  Fournie,-  and  of  others.  We  must 
retrace  our  steps  considerably.  We  have  seen  the  very  crude  ideas 
of  Democritus,  Hippocrates,  and  Aristotle,  and  we  have  to  regret 
the  lost  treatise  of  Galen  on  the  voice,  which  perhaps  would  have 
revealed  to  succeeding  generations  clearer  ideas  on  the  subject. 
We  find  in  all  the  pre-Henaissance  and  Arabian  works  constant 
reference  to  Galen's  conception  of  the  larynx — in  mediaeval  Latin, 
the  "principalissimum  organum  vocis."  The  first  reference,  which 
I  have  noted  after  Galen,  to  a  more  extended  and  exact  conception 
of  laryngeal  physiology  is  to  be  found  in  the  remark  of  Pare  on 
the  anatomy  of  the  larynx:  "When  the  cartilages  are  open  the 
voice  is  large  like  the  Basse-Contre.  On  the  contrary,  when  they 
are  compressed,  the  voice  is  shrill."  It  was  long  after  the  time  of 
Pare  before  the  matter  was  taken  up  as  a  separate  study.  Casserius 
indeed,  in  his  work  on  the  larynx,  discusses  voice  formation  to  a 
considerable  length,  as  did  many  other  anatomists  incidentally, 
but  it  was  Claude  Perrault  (1613-16SS)  who  first  explained  the 
\oice  by  mechanical  laws  and  especially  endea^•ored  to  demon- 
strate that  it  is  produced  only  by  the  larynx  without  the  trachea 
taking  any  immediate  part  in  it.''  He  compared  the  larynx  in 
birds  and  animals  with  the  human  organ.*  "As  regards  the  tone 
of  the  voice,  it  is  low  and  grave  when  the  glottis  makes  a  long  slit, 
because  this  makes  the  lips  relaxed  and  their  vibrations  slower." 
He  insisted  that  the  upper  parts  of  the  air  passages  take  part  in 
the  formation  of  the  voice.  He  likened  it  to  a  flute,  the  muscles 
of  the  larynx  working  the  variations. 

Shortly  after  this  Dodart'^  took  the  matter  up.  He  insisted  that 
the  trachea  only  furnishes  the  material  of  the  voice,  /.  e.,  the  expired 
air.  The  glottis  is  the  only  organ  of  the  voice.  All  the  effects  of 
the  glottis  for  tones  depend  on  the  tension  of  its  lips,  and  of  its 
various  internal  structures.     The  concavity  of  the  mouth  has  no 

'  Holmes:  Treatise  on  Vocal  Physiology  and  Hygiene,  London,  1879. 

2  Fourni6:  Physiologic  de  la  Voix  et  de  la  Parole,  Paris,  18G6. 

'  Sprengel:  1.  c.,  V,  150. 

^  Oeuvres  Diverses  de  Physique  et  de  M6chanique,  Edit.  1721,  Vol.  2,  p. 
392;  also  Ibid.,  Vol.  I,  p.  220,  II  partio,  Du  Bruit. 

^  IMenioire  sur  les  causes  de  la  Voix  de  I'Homme,  par  M.  Dodart,  Hist, 
de  I'Acad^mie  des  Sciences,  1700,  p.  308 


VOICE  PRODUCTION  191 

part  in  the  production  of  the  voice,  but  it  is  a  modifier  of  it,  and 
still  more  is  this  true  of  the  nose.  He  showed  that  Galen's  compari- 
son to  a  flute  could  not  be  accepted,  if  one  went  into  details.  He 
spoke  of  the  vibrations  of  the  ligaments,  and  of  the  dilatations 
and  contractions  of  the  glottis.  He  asserted  the  trachea  is  elongated 
in  high  notes,  and  shortened  in  low  ones.  He  likened  the  vocal 
organ  rather  to  a  horn  or  trumpet.  x\ccording  to  him,  the  glottis 
is  the  place  which  corresponds  to  the  lips  of  the  musician ;  the  body 
of  the  instrument  extends  from  the  glottis  to  the  external  orifice  of 
the  vocal  canal,  that  is  to  say,  to  the  mouth. 

In  1742  Ferrein  modified  the  conception  of  Dodart  somewhat 
by  comparing  the  larynx  to  a  stringed  instrument  such  as  the 
^•iolin.^  He  was  the  first  in  accordance  with  this  idea  to  apply 
the  name  "vocal  cords"  to  the  lips  of  the  glottis.  Dodart,  as  we 
haA'e  seen,  had  taken  note  of  the  oscillations  of  these  ligaments, 
but  Ferrein  more  particularly  saw  in  them  the  principal  instruments 
of  the  modulation  of  the  voice,  and  he  reported  a  number  of  obser- 
^•ations  which  tended  to  prove  that  the  air  in  striking  the  glottis 
produced  different  tones  according  to  the  vibrations  which  these 
parts  performed.  Bertin,  in  1745,  inclined  to  the  simile  of  Dodart, 
asserting  that  the  vibration  of  the  glottis  was  not  sufficiently  free 
to  allow  comparison  with  the  oscillation  of  cords.  Ferrein's  ^'iew 
was  adopted  by  Montagnat  (1746),  who  called  attention  to  the 
second  larynx  in  birds,  which  is  supplied  with  a  taut  membrane 
which  is  able  to  produce  the  same  notes  as  the  ligaments  of  the 
glottis.  Haller  in  his  great  work^  wrote  a  long  dissertation  upon 
the  voice  and  the  parts  played  in  its  formation  by  the  various 
structures  of  the  nose  and  throat,  referring  to  the  accessory  sinuses 
as  having  the  function  of  making  the  voice  more  sonorous.  He 
seems,  however,  to  have  added  very  little  that  was  original  to  our 
actual  knowledge,  and  the  same  may  be  said  of  Walther,'^  but  the 
latter  has  much  to  say  of  the  intralaryngeal  movements. 

We  should  not  pass  on  to  the  nineteenth  century  in  this  matter 
without  taking  note  of  the  noble  labors  of  Johann  Conrad  Amman.* 
Although  Hartmann  says  that  the  Spanish  Benedictine  monk, 
Pedro  de  Ponce,  in  the  sixteenth  century,  proved  that  deaf  mutes 
can  be  taught  to  speak,  Amman's  is  the  first  treatise  upon  a  method 
of  teaching  the  mute  to  talk.  He  followed  practically  the  same 
method  of  teaching  as  is  now  used  in  the  various  institutions  for 
that  purpose,  i.  e.,  lip  reading. 

Under  the  impetus  of  the  new  life  in  France,  ^Magendie  took  up 
the  study  of  voice  production  where  it  had  halted  for  the  best  part 

1  Vid.  Sprengel,  1.  c,  and  Colombat:  Traite  des  Maladies  et  do  I'Hygiene 
des  Organes  de  la  Voix,  1838,  p.  50. 

2  Eleinenta  Physiologica,  Lilj.  IX,  Lausanne,  1761,  III,  p.  .36(i. 

^  De  Hominis  Larvnge  et  Voce.     Haller's  Disp.  Anatom.,  1749,  Vol.  IV, 
p.  691. 
*  Surdus  Loquens  sive  Dissertatio  de  Loquela,  1740. 


192  THE  PRE-LARYNGOSCOPIC  ERA 

of  a  hundred  years.  lie  was  the  first  who  actually  saw  by  experi- 
mentation on  animals  the  vibration  of  the  vocal  cords  in  vivo. 
He^  again  more  confidently  compared  their  actions  to  the  vibrating 
bands  of  wind  instruments,  this  in  animals  depending  on  the 
contraction  of  the  laryngeal  muscles  rendering  the  ^'ocal  cords 
taut,  the  intensity  and  \olinne  of  the  voice  depending  on  the 
extent  of  the  vibrations,  and  this  depending  on  the  length  of  the 
cords,  the  size  of  the  larynx  and  the  amount  of  the  expulsive  force 
of  the  air  current.  In  contradistinction  to  Ferrein,  he  taught  that 
the  tones  of  the  voice  depended  not  so  much  on  the  tension  of  the 
cords  as  upon  the  length  of  their  \ibrating  surfaces,  deep  tones 
l)eing  due  to  the  \ibration  of  the  whole  length  of  the  cord,  and  the 
high  notes  to  the  vibrations  only  of  the  posterior  portions,  varying 
with  the  height  of  the  note.  The  larynx  rises  in  high  notes  and 
descends  in  the  low  notes,  thus  lengthening  and  shortening  the 
vocal  tube.  He  regarded  the  ventricles  of  the  larynx  as  anatomical 
devices  to  allow  of  the  separation  of  the  true  from  the  false  cords. 
He  differed  from  Bichat  in  supposing  the  epiglottis  to  have  some- 
thing to  do  with  the  formation  of  the  voice.  He  also  noted  the 
modifications  of  the  voice  by  the  cavities  of  the  mouth  and  nose. 
Holmes  (1.  c.)  refers  to  Liscovius  as  having  dwelt  upon  the  impor- 
tance of  the  width  of  the  vocal  slit  in  voice  production,  a  matter 
appreciated,  as  w^e  have  seen,  by  Dodart  and  exaggerated  by  Pare 
before  him.  Sehfeldt,  in  1835,  was  the  first  to  state  that  the  falsetto 
voice  is  produced  by  the  action  alone  of  the  edges  of  the  vocal 
cords.  Holmes  says  that  Biot  in  1816  originated,  and  Cagniard 
de  la  Tour  by  his  invention  of  the  siren-  in  182")  demonstrated  the 
accepted  theory  of  sound  producetl  by  the  \il)ration  of  tongued 
instruments. 

flayer'  and  the  great  Johann  IMiiller^  wrote  at  great  length  on 
the  subject,  but  in  a  manner  most  discouraging  to  the  modern 
reader.  In  this  respect,  however,  they  were  surpassed  by  Harless.-^ 
Pie  wrote  a  two-hundred-page  article  on  the  voice,  in  which  the 
most  exhaustive  examination  of  the  anatomy  of  the  parts  was 
made.  Histological,  chemical,  dynamic  inxestigations  are  detailed 
with  unwearied  industry  and  indefatigable  zeal.  Its  very  ponder- 
osity has  buried  it  in  oblivion.  It  is  highly  probable  that  a  careful 
.study  of  it  might  reveal  matters  of  interest  to  the  modern  student, 
brave  enough  to  undertake  the  task. 

This  brings  us  up  to  Garcia's  invention,  which  revolutionized 

1  Magondie:  Pri^cis  Elempntaire  do  Physiologic,  Paris,  1816,  I,  p.  210. 

^  The  siren  consists  of  a  revolving  })late  pierced  l)y  holes  at  its  circumference, 
through  which  on  passing  in  its  revolutions  over  an  ajxTture  air  is  forced,  the 
rajiidity  of  the  revolutions  regulating  the  pitcli  of  the  nuisical  note  i)roduced. 

^  Mayer:  Archiv  fiir  Anatomic  und  Physiologic,  Berlin,  1826,  p.  188. 

■•  Miiller:  Handbuch  der  Physiologic  dcs  Menschen,  Coblenz,  1840-2,  p.  179. 

^  Emil  Ilarless:  Wagner's  Handworterbuch  der  Ph3^siologie,  Braunschweig, 
18.53,  IV,  p.  .50.5. 


LARYNGEAL  PHTHISIS  193 

the  study  of  voice  production.  ]\Iany  works  rapidly  appeared, 
among  which  may  be  mentioned  Merkel's  "Funktionen  des  ]\Ien- 
schhchen  Schkuid  und  Kehlkopfes"  (1862).  He  had  previously, 
before  the  importance  of  the  afl\Tnt  of  the  laryngoscope  was 
appreciated,  written  his  "  Anthropophonik."  In  1861  Bataille 
in  a  memoire^  presented  to  the  Academy  of  Sciences,  following  up 
the  suggestion  of  Garcia,  advanced  very  decidedly  the  knowledge 
of  the  finer  intralaryngeal  movements  in  phonation  and  in  singing, 
though  his  results  were  stated  somewhat  dogmatically.  Notwith- 
standing the  invention  of  the  laryngoscope  and  the  numerous 
exhaustive  monographs  on  the  subject  of  voice  formation,  among 
which  may  be  noted  Griintzner's,-  little  was  established  beyond 
what  had  been  discussed  in  pre-laryngoscopic  days. 

Photography. — The  photography  of  the  larynx  by  French,^  a 
triumph  of  ingenuity,  skill,  and  persistence,  resulted  in  upsetting 
many  of  the  ideas,  conceived  not  only  by  the  early  investigators, 
but  much  also  which  had  been  advanced  since  the  introduction  of 
the   laryngoscope. 

Modern  Theories. — AYillis,  in  1830,  advanced  the  idea  that  the 
\ibration  of  the  air  in  the  cavity  of  the  mouth  was  independent 
of  the  vibration  of  the  laryngeal  air,  and  thus  the  formation  of 
the  voice  was  a  complex  process.  This  idea  was  superseded  by 
the  somewhat  similar  but  modified  overtone  theory  advanced 
by  Helmholz,^  who  derived  the  idea  from  Wheatstone.^  This  has 
since  been  the  prevailing  theory  of  voice  production,  which,  with 
modern  apparatus  of  precision,  has  been  so  scientifically  investi- 
gated by  Professor  Edward  \V.  Scripture.'' 

Laryngeal  Phthisis. — Littre^  seems  to  think  a  passage  in  "Disease 
II  "  is  a  proof  that  Hippocrates,  or  rather  the  author  of  this 
Hippocratic  treatise,  had  observed  phthisis  laryngea,  because  he 
alludes  to  ulcers  in  the  tube  of  the  lungs.  If  we  are  to  suppose 
that  this  book  had  its  origin  in  the  School  of  Alexandria,  where 
they  were  familiar  with  the  dissection  of  the  human  body,  this 
may  be  a  valid  conjecture. 

Before  the  advent  of  laryngoscopy  there  was  considerable 
progress  made  not  only  toward  the  correct  understanding  of 
tubercular  disease,  but  toward  the  recognition  of  its  manifestation 
in  the  larynx.  Virchow  has  pointed  out*  how  a  mistaken  inter- 
pretation of  Sylvius  de  la  Boe  led  him  to  confound  small  tubercular 
cavities  in  the  lungs  with  suppurating  conglomerate  glands.    Glinical 

1  Nouvelles  Rechcrchcs  sur  la  Phonation,  1861.  Ref.;  Gaz.  Hebd.  de  Med. 
et  Chiruru;.,  17  Mai,  VIII,  p.  30S. 

2  Hermann's  Ilandbuch  tl(n-  Physiologic,  Leipzig,  1879,  Band  I,  2"^  th. 
^  Trans.  Am.  Lar.  Assoc,  1SS3,  p.  59. 

*  Lehre  von  don  Tonompfindungon,  Braunschweig,  1863. 

*  London  and  ^^'est  minister  Review,  1837.  ^  Experimental  Phonetics. 
^  Littre:  (Euvres  Completes  d'Hippoorate,  Tome  VII,  p.  77. 

8  Die  Krankhaftcn  (jeschwiilste,  Berlin,  1864-5,  III,  p.  621  et  seq. 
13 


194  THE  PRE-LARYNGOSCOPIC  ERA 

observation  had  frequently  noted  the  enlargement  of  the  so-called 
ronirlobate  glands  associated  with  e^■idences  of  pulmonary  phthisis. 
From  this,  and  subsequently  through  the  works  of  ]\lorgagni, 
Cullen  and  many  others,  the  conce])tion  gradually  arose  that  there 
was  a  pathological  connection  between  vomicae  in  the  lungs  and 
the  enlarged  lymph  glands.  This  is  a  singular  instance  of  how  out 
of  error  much  that  is  true  in  pathogenesis  arose.  We  have  seen 
Sylvius  de  la  Boe  interested  in  se])arating  the  conglobate  from  the 
conglomerate  glands,  and  we  need  not,  therefore,  be  suri)rised  at 
finding  him  mistaken  as  to  the  cavity  of  the  dilated  conglomerate 
glands  being  identical  with  foci  of  suppuration  in  the  lungs. 

Morgagni. — The  history  of  the  growth  of  our  knowledge  of  laryn- 
geal phthisis  is  usually  traced  back  to  ]\Iorgagni.  Again  we  note 
that  growth  means  differentiation.  Tuberculosis  and  sy])hilis 
are  inextricably  confused  in  the  early  accounts  of  phthisis  laryngea. 
According  to  Morgagni  in  his  discourse  on  the  lesions  of  respiration, ^ 
P'antoni  had  noted  in  the  cada^•er  of  a  man  the  mucosa  of  the 
arytenoid  cartilages  so  ulcerated  and  thickened  that  there  only 
remained  a  very  small  laryngeal  opening  through  which  the  i)atient, 
who  had  lived  in  this  condition  a  long  time,  had  breathed  with 
great  difficulty.  Morgagni  then  described  the  case  of  a  woman  of 
forty  who  had  been  asthmatic  for  some  time,  and  she  ha\ing  died, 
nothing  was  found  in  the  lungs  or  brain  to  account  for  her  symptoms. 
At  Morgagni's  suggestion,  the  larynx  was  brought  to  him.  He 
opened  it  from  behind  and  pus  of  a  grayish  color  flowed  out,  and 
from  such  a  situation  that  the  swelling  it  caused  must  have  pro- 
jected into  the  larynx  and  produced  dyspncpa.  Notwithstanding 
this  memorable  case  has  been  frequently  cited  as  one  of  tu})ercular 
laryngitis,  I  am  very  much  of  the  opinion  that  it  was  a  case  of 
syphilis.  However  that  may  have  been,  evidently  it,  with  some 
other  similar  observations  reported  by  Bonet,  Santorini,  and 
others,  impressed  ]\Iorgagni  with  the  necessity  of  directing  attention 
to  the  larynx  in  cases  of  dyspno-a,  not  only  at  postmortem  exami- 
nations but  clinically.  He  did  not  fail  to  lay  emphasis  on  this 
point,  and  his  remarks  soon  aroused  interest  in  the  study  of  such 
lesions. 

Lieutaud,  who,  in  a  \ery  inferior  manner,  continued  the  work 
of  Morgagni,  reported^  several  cases,  which  at  postmortem  pre- 
sented lesions  in  the  larynx  which   mav  have  been  tubercular. 

Petit  (1790),  Portal  (1792),  Sauve  (1S02),  Saignelet  (1806), 
wrote  theses  on  laryngeal  phthisis  in  which  it  is  difficult  to  separate 
the  syphilitic  from  the  tubercular  cases,  but  in  which  the  various 

1  De  Sedibus  et  Causis  Morborum.  Lib.  II,  De  Morbis  Thoracis.  Epist. 
Anat.  Med.,  XV,  Art.  12. 

2  Historia  Anatomica  Mcdica,  Lib.  IV,  Parisiis,  17G7,  II,  p.  297  et  seq.  Obs. 
6.5,  67,  67a,  68.  The  last  observation  presents  more  satisfactory  evidence  of 
the  lesions  having  been  tubercular  than  the  others. 


LARYNGEAL   TUBERCLE  195 

symptoms  and  lesions  common  to  both  are  set  forth  at  length, 
^Matthew  Baillie/  in  1793,  noted  freqnent  appearances  in  the 
lungs  at  postmortem  to  which  he  ga\e  the  name  of  tubercle,  but 
he  declared  they  did  not  occur  in  the  branches  of  the  trachea 
"  where  there  are  follicles.  They  are  solid  or  they  may  break 
down."  Neverthless,  it  would  appear,  in  the  edition  published  in 
1825,  after  his  death,  that  he  had  observed  the  walls  of  the  trachea 
thickened  and  the  mucosa  covered  by  little  hard  tubercles  accom- 
panied by  a  scirrhous  affection  of  the  glands.  He  also  referred 
to  inflammation  of  the  tracheal  mucosa  and  its  ulceration  "where 
there  are  scrofulous  abscesses  of  the  lungs.  The  same  appearances 
are  observable  in  the  mucous  membranes  of  the  larynx."- 

Laryngeal  Tubercle. — Whatever  may  ha\'e  been  the  real  conditions 
referred  to  by  Baillie,  Broussais,^in  180G,  noted  white  miliary  tuber- 
cles in  the  larynx  of  a  man  dead  of  pidmonary  phthisis.  There  was 
also  an  ulceration  in  the  ventricles  of  the  larynx.  His  observation 
seems  to  have  been  first  published  in  1816.  Previous  to  this  Bayle^ 
had  published  his  varieties  of  phthisis  pulmonalis,  the  first  of  which 
was  tubercular.  He  described  its  three  stages:  the  state  of  tubercle, 
its  softening,  its  cavernous  or  cystic  stage.  He  is  also  said  to  have 
been  the  first  to  make  use  of  the  term  "tubercular  diathesis."^ 

While,  therefore,  tubercle  had  been  recognized,  not  only  in  the 
lungs  but  in  the  larynx,  before  Laennec's  publications,  he  more 
clearly  and  definitely  than  others  pointed  out  the  characteristic 
lesion,  to  which  he  himself  fell  a  victim,  dying,  in  1820,  at  the  age 
of  fortv-five.  In  his  treatise  on  the  Diseases  of  the  Chest, ^  he 
thus  defines  phthisis  pulmonalis  at  the  beginning  of  his  book: 
"The  existence  in  the  lungs  of  those  peculiar  productions,  to  which 
the  name  tubercle  has  been  restricted  by  modern  anatomists,  is 
the  cause  and  constitutes  the  true  anatomical  character  of  con- 
sumption." He  described  their  formation,  regarding  them  as 
ad^'entitious  matter  forming  in  the  pulmonary  tissue. 

A  very  full  and  satisfactory  account  of  the  condition  of  the 
knowledge  of  laryngeal  phthisis  prior  to  Louis'  celebrated  work 
may  be  found  in  the  thesis  of  Pravaz.^  I'nfortunately  we  are  still 
in  a  position  to  thoroughly  understand  the  vivid  impression  made 
upon  the  author  by  the  death  of  his  mother  from  this  formidable 
affection,  and  we  also  understand  his  bitter  quotation  of  the 
expression  of  Asclepiades  in  regard  to  Hippocratic  medicine  where 

1  Morbid  Anatomy  of  Some  of  the  Most  Important  Parts  of  the  Human  Body, 
London,  179.3. 

-  The  Works  of  Matthew  BaiUie,  London,  182."),  Vol.  II,  p.  84  et  seq. 
^  Histoire  des  Plilegmasies,  Paris,  ISlfi,  I,  p.  372. 

*  Recherches  sur  la  Phthisic  Pulmonaire,  Paris,  1810. 

*  Jour,  de  Med.  Chirurg.  and  Pharm.,  etc.,  Paris,  An.  XI,  T.  VI,  p.  3. 
6  Translated  by  John  Forbes,  1823. 

^  Recherches  pour  servir  a  I'Histoirc  de  la  Phthisic  Laryngee.  These  de 
I'Ecolc  de  Medecine  de  Paris,  No.  56,  1824. 


196  THE  PRE-LARYNGOSCOPIC  ERA 

he  says  it  was  tlie  contemplation  of  deatli.  He  says,  "Xo  one 
can  doubt  today  tliat  laryngeal  i)lithisis  may  exist  primarily." 
This  to  the  modern  reader  is  explained  l)y  the  citation  of  such 
cases,  cured  by  the  administration  of  mercury. 

There  is  a  notice  in  a  publication^  in  1818  that  creosote  was 
used  in  the  form  of  a  fumigation  of  tar,  and  it  was  suggested  that 
this  might  be  useful  in  laryngeal  phthisis,  but  as  a  rule  treatment 
was  regarded  as  of  no  avail. 

Louis  on  Phthisis  and  Catarrhal  Ulcers  of  the  Larynx. — The  advent 
of  the  more  exact  methods  of  diagnosticating  j)ulmonary  disease 
by  physical  examination,  corresponding  to  the  more  general  study 
of  its  anatomical  lesions,  resulted  in  a  considerable  increase  of 
attention  given  to  tubercular  lesions  of  the  upper  air  tubes.  The 
work  of  Louis-  forms  an  integral  part  of  the  history  of  Phthisis, 
but  in  a  work  of  more  than  500  pages  hardly  fifty  are  devoted  to 
the  manifestations  of  the  disease  in  the  "tracheal  artery,"  the 
larynx  and  the  epiglottis.  To  the  lesions  of  the  latter  he  devoted 
especial  attention.  In  102  cases  at  autopsy  the  upper  air  tubes 
were  examined  and  lesions  were  found — of  the  epiglottis  18,  of 
the  larynx  22,  of  the  trachea  31.  While  he  did  not  recognize,  as 
did  Broussais,  tubercle  in  the  larynx,  he  supplemented  the  work 
of  Laennec  by  its  careful  description  in  the  lungs.  The  work  of 
Louis  is  more  frequently  quoted  in  laryngology  as  having  given 
origin  to  the  idea  that  the  ulcers  of  the  larynx  in  phthisis  are  due 
to  the  mechanical  raspings  of  secretions,  cast  off  from  the  tuber- 
cular lesions  of  the  pulmonary  tissue.  This  mistaken  conception 
has  hardly  yet  entirely'  disappeared  from  our  nosology  of  disease, 
in  spite  of  the  early  work  of  Rokitansky  and  Virchow.  This  was 
asserted  not  only  in  the  first  edition  of  his  work,  but  repeated  in 
the  second  edition  in  1843.  He  seems  to  have  been  the  first  to  use 
the  term  and  to  draw  attention  to  the  existence  of  latent  ])hthisis, 
a  matter  with  which  advancing  science  has  made  us  more  familiar. 

While  far  less  exhaustive  and  valuable  we  may  note  in  the  work 
of  Andral  in  1834'^  more  accurate  views  than  those  of  Louis  as  to 
some  matters  pertaining  to  laryngeal  phthisis.  He  gave  a  long 
description  of  it,  noting  the  occurrence  of  tubercle  in  the  larynx. 

Trousseau  and  Belloc.  Barth,  writing  in  1830,  referred  to  fifteen 
or  sixteen  authors  who  had  by  that  time  written  on  the  subject 
of  laryngeal  phthisis.  By  far  tlic  most  exhaustive  and  the  most 
valuable  was  the  work  of  Trousseau  and  Belloc,'*  which  still  remains 
a  classical  authority  on  the  subject.  'J'heir  difl'erentiation  of  the 
lesions  was  still  far  from  perfect,  but  they  were  aware  of  this  con- 

• 

1  Dictionnaire  des  Sciences  Mcdicales,  Paris,  1818,  Vol.  XXVII,  p.  264. 
^  Recherches  Anatomico-Pathologiques  sur  la  Phthisis,  A.  Louis,  Paris,  1825. 
5  C'linique  Medicalo,  li  od.,  Paris,  lS:i4,  ')  vols. 

'' Traite  Pratique  do  la  Phthisie  Laryngec,  de  la  Laryngite  Chronique,  et 
des  Maladies  de  la  Voix,  Paris,  1,S37. 


ROKITANSKY  197 

fusion  in  the  works  of  previous  writers.  Thus  they  quote  Borsieri 
as  saying  in  182(3:  "There  are  those  who  think  ulcers  of  the  larynx 
and  the  aspera  arteria,  because  they  are  not  situated  in  the  lungs, 
should  be  excluded  from  phthisis.  However,  from  these  lesions 
also  the  body  often  wastes  away,  and  is  consumed  by  a  slow  fever 
just  as  in  the  parent  disease."  Their  assertion  that  he  was  the 
first  to  recognize  laryngeal  phthisis  as  in  itself  an  essential  disease 
is,  as  we  have  seen,  hardly  accurate.  They  included  in  their 
category  of  laryngeal  phthisis: 

1.  Simple  laryngeal  phthisis  produced  by  the  common  causes  of 
inflammation  in  general,  without  pulmonary  phthisis. 

2.  Syphilitic  laryngeal  phthisis. 

3.  Cancerous  laryngeal  phthisis. 

4.  Tubercular  laryngeal  phthisis. 

Notwithstanding  their  recognition  of  tubercle  in  their  last 
division,  we  see  in  their  first  the  influence  of  the  catarrhal  theory 
of  Louis,  and  the  evidence  of  insufficient  dift'erentiation  and  faulty 
diagnosis,  while  their  other  two  classes  give  evidence  of  a  con- 
siderable ad\'ance  in  dift'erential  diagnosis  over  the  works  of  their 
predecessors.  Practically,  however,  when  we  come  to  study  the 
reports  of  many  of  the  cases  classified  thus,  we  will  find  consider- 
able confusion.  In  this  respect  the  slightly  later  memoir  of  Barth^ 
gives  evidence  of  a  more  correct  understanding,  as  he  separated 
more  intelligently  the  syphilitic  from  the  tubercular  cases.  We 
may  now  note  the  beginning  of  a  more  careful  limitation  and 
definition  of  the  word  tubercle.  Hodgkin-  notes  a  distinction,  first 
that  the  term  is  applied  to  the  shape  or  contour  of  a  formation, 
and   second  to  adventitious  deposits  as  first  used   by  Laennec. 

Rokitansky. — We  have  now  arri\ed  at  the  time  of  Rokitansky, 
who  inaugurated  a  svstem  of  studv  of  morbid  lesions,  which  was 
far  in  advance  of  anything  which  had  yet  appeared  in  ^Medicine. 
Many  of  his  ideas  are  now  rejected,  but  many  more  contained  the 
germs  of  doctrines  which  still  rule  in  the  field  of  pathological 
medicine.  In  accuracy  they  were  far  in  advance  of  contemporaneous 
research,  and  rapidly  gained  almost  universal  acceptance,  especially 
his  errors.  He  also  looked  on  tubercle  as  an  exudate  of  coagulated 
protein  stuft",  and  in  this  era,  when  the  knowledge  of  the  cell  was 
still  in  its  infancv,  he  asserted  that  this  exudate  was  eml)r\()nic 
tissue,  or  Blastema  which  had  not  yet  undergone  organization.^ 
He  nevertheless  recognized  that  the  ulcers  occurred  from  the  break- 
ing down  of  this  tubercular  exudate.  Me  regarded  primary  tuber- 
culosis of  the  larvnx  as  an  exceedinuh'  rare  afl'ection.    The  lesion 

1  Memoire  sur  les  ulcerations  dcs  voies  acriennes.  Archives  Gen(!'rales  de 
Medecine,  Paris,  1839,  3me.  serie,  Vol.  V,  p.  137. 

2  Lectures  on  the  Morl)i(l  Anatomy  of  the  Serous  and  Mucous  Membranes, 
bj^  Thomas  Ilodskin,  ISK),  Vol.  II,  p.  132. 

"3  Handbuch  der  Path.  Anat.,  Wien,  1846,  Band  I,  p.  391. 


198  THE  PRE-LARYNGOSCOPIC  ERA 

of  tul^ercle  was  more  carefully  described  than  ever  before,  and  at 
last  we  note  there  is  here^  no  indication  of  his  confounding  it  with 
syphilis.  In  continuing  the  history  of  the  old  conception  of  tubercle, 
I  need  only  refer  to  the  paper  of  Rheiner,  ten  years  later ,2  in  which 
again  appeared  the  idea  of  Louis,  that  the  ulcerations  of  laryngeal 
phthisis  are  mechanical  and  catarrhal  in  their  origin. 

^Ye  may  here  take  note  of  matters  of  further  interest  in  the 
works  of  Kokitansky.  In  spite  of  his  careful  obser\ations  he  spoke 
of  the  existence  of  dilatation  of  the  larynx,  corresponding  to  the 
condition  of  bronchiectasis  in  the  lungs.  He  dealt  in  a  systematic 
way  with  the  hypera^mia  and  amemia,  the  acute  and  chronic 
inflammations  of  the  mucosa^  of  the  upper  air  passages,  their 
hypertrophy  and  atrophy,  noticing  the  changes  in  the  glands  and 
describing  polypi  as  a  result  of  inflammatory  action.  It  is  a  little 
difficult  to  understand  the  nature  of  the  condition  he  refers  to  as 
blennorrhoeal  catarrh  and  stenosis  of  the  larynx.  Besides  his 
mistaken  conception  of  tuberculosis,  he  more  accurately  described 
the  exudative  processes  of  croupous  inflammation,  dividing  them 
into  several  varieties,  including  the  "true  croup"  of  children.  He 
spoke  of  the  lesions  in  the  air  passages  of  variola  and  typhus  fever 
as  submucous  processes  involving  ulceration  of  the  mucosa  and 
perichondritis.  He  described  benign  epithelial  growths,  mucous 
polypi,  and  the  laryngeal  excrescences  of  syphilis  and  tuberculosis. 
Fibrous  tumors  are  also  noted  as  well  as  malignant  growths.  In 
short,  in  the  pathology  of  the  larynx  as  well  as  in  that  of  other 
regions  we  cannot  fail  to  remark  the  great  services  rendered  by 
Kokitansky.  I'nfortunately  lesions  in  the  air  passages  above  the 
larynx  did  not  receive  the  same  careful  study  at  his  hands. 

(Edematous  Laryngitis. — As  a  contrast  to  the  importance  which 
the  word  tubercle  has  assumed  in  our  terminology,  the  reader  of 
the  medical  literature  of  this  period  will  And  much  said  of  another 
phenomenon  of  disease  in  the  larynx  described  by  Bayle.  Among 
the  conditions  which  later  studies  in  pathology  have  banished 
from  the  nosology  of  disease  as  an  entity  in  itself,  we  frequently 
recognize  the  term  (Edematous  Laryngitis.  The  early  treatise 
of  Bayle,^  in  1817,  however,  cannot  be  justly  blamed  for  having 
failed  to  give  the  term  its  proper  place,  for  the  author  declared 
that  it  was  a  stage  of  many  local  and  general  diseases.  Nevertheless 
many  subsequent  writers  accepted  the  designation  as  creating  a 
proper  basis  of  classification  for  many  cases.  Sestier,-*  especially, 
in  a  ^•oluminous  work  in  1852,  attempted  to  bring  many  funda- 
mentally difl'erent  pathological  conditions  into  one  category  on 
this  basis. 

1  1.  c,  Vol.  ]I1,  1).  3G.  =  Virchow's  Archiv,  Berlin,  1853,  V,  534. 

'  CEdcme  de  la  (ilotte  on  Anginc  Laryngoe  (Ed6matcuse.    Diet,  des  Sciences 
Medicales.     Paris,  1817,  T.  18,  p.  o()5. 
*  Trait6  de  I'Angine  Laryngee  CEdemateuse,  Paris,  1852. 


EPITHELIUM  OF  THE  MUCOUS  MEMBRANES  199 

"Ludwig's  Angina." — Some  years  before  this  D.  Ludwig'  de- 
scribed a  clinical  condition  arising  from  infection  of  perilaryngeal 
tissues  which  is  still  described  under  his  name.  "  Ludwig's  Angina," 
on  any  basis  of  etiological  classification,  in  spite  of  its  peculiar 
condition  of  board-like  hardness,  deserves,  as  little  as  Bayle's 
"Q'^dematous  Angina,"  a  place  in  modern  nosolog}'. 

The  Cell. — We  cannot  proceed  further  in  an  intelligible  account 
of  any  part  of  the  history  of  medicine  without  a  few  words  as  to 
the  history  of  the  discovery  of  the  cell.  It  would  be  difficult  to 
understand  how  the  early  microscopists  failed  to  note  more  fre- 
quently and  to  study  more  carefully  this  unit  of  all  living  matter 
in  the  animal  and  ^•egetable  world,  were  we  to  forget  the  small 
range  of  their  magnifying  glasses,  the  imperfection  of  the  correction 
of  the  aberration  of  light,  and  more  especially  the  imperfect  tech- 
nique in  preparing  solid  tissues  for  microscopic  examination.  An 
English  physician,  Robert  Hooker,  in  1665,  examining  with  a 
glass  a  little  section  of  cork,  saw  cavities  in  it  which  he  called 
cells  and  likened  to  a  honey-comb.  Subsequently,  in  1671,  Grew 
and  Malphigi  comprehended  something  of  the  significance  of  this 
discovery  of  the  structure  of  the  vegetable  kingdom.  It  was 
another  Englishman,  Robert  Brown,  who  first  noted,  in  1831, 
that  in  many  families  of  plants  a  circular  spot  which  he  named 
areola  or  nucleus  was  present  in  each  cell;  and  in  1838  M.  J. 
Schleiden  asserted  that  a  similar  spot  or  nucleus  was  a  universal 
elementary  organ  in  \egetables.  The  same  phenomena  had  begun 
to  be  observed  in  animal  structures,  and  in  1839  Schwann,  a  pupil 
of  that  man  of  genius,  Johannes  Miiller,  announced  the  important 
generalization  that  there  is  one  universal  principle  of  development 
for  li\-ing  organisms  and  that  is  the  formation  of  cells.-  The  fruits 
of  the  labors  of  these  men  and  others,  their  predecessors  and  con- 
temporaries, were  spread  broadcast  over  all  fields  of  medicine, 
and  Virchow's  apothegm  "Omnis  cellula  e  cellula"  became  the 
shibboleth  of  pathology  after  the  middle  of  the  century. 

Epithelium  of  the  Mucous  Membranes. — Henle,^  as  early  as  1838, 
declared  that  the  mucous  membranes  of  the  body  are  lined  with 
epithelium,  and  in  regard  to  the  nasal  mucosa  he  said:  "PVom 
the  openings  of  the  nares  the  pavement  epithelium  extends  inter- 
nally' for  some  distance  upon  the  nasal  septum  as  well  as  upon  the 
alffi  nasi,  on  a  line  which,  upon  the  septum  and  upon  the  lateral 
walls  of  the  nose,  one  may  inuigine  as  being  drawn  from  the  free 
border  of  the  nasal  bone  to  the  anterior  spine,  occurs  the  change 

1  Modicinisches  Correnspondenz-Blatt  dcs  Wiirttem.  Aerztl.Vei'eins,  Stuttgart , 
1836,  VI,  No.  4,  Feb.  5,  p.  21. 

2  Vid.  Sir  William  Turner's  Presidential  Address,  The  Populai-  Science 
Montlily,  October  and  November,  X.  Y.,  1900,  LVH,  p.  501;  LVIII,  p.  34; 
also  llennesu}',  Legons  sur  la  Cellule,  Paris,  1896. 

^  Aroliiv  fiir  Anatomic,  Physiologic,  etc.,  1838,  p.  103. 


200  THE  PRE-LARYN(^OSCOPIC  ERA 

from  a  ijaveinent  epitlu'lium  to  a  ciliated  epitlu'liuin."     Later,  in 
1848,'  he  more  exhaustively  treated  the  whole  subject. 

The  Tonsils.  William  Bowman,-  in  1845,  described  the  sweat 
inlands  of  the  skin  as  tubular  diverticula.  lie  subsequently^  de- 
scribed similar  structures  in  the  nasal  mucosa,  which  in  the  mean- 
while Kcilliker'  had  also  noted  in  the  mucosa  of  the  U])])er  part  of 
the  nose,  and  to  which  he  had  given  the  name  of  Bowman's  glands. 
The  racemose  glands  of  the  mucosa,  as  w^e  have  seen,  had  long  since 
been  known.  Henle  (1.  c.)  had  regarded  the  tonsils  as  of  a  similar 
nature,  and  even  as  late  as  18G6^  he  is  somewhat  obscure  as  to 
their  character,  retaining  the  old  name  suggested  by  Sylvius  de 
la  Boe  of  the  conglobate  glands  of  the  pharynx.  It  was  Kolliker^ 
who  first  properly  described  these  structures  at  the  base  of  the 
tongue  and  in  the  fauces.  He  studied  them  in  their  simple  forms 
in  animals,  but  while  he  described  the  folds  and  depressions  of  the 
mucostie  and  the  follicles  in  their  walls  and  the  epithelium,  the 
finer  structure  of  the  lymphatic  net-work  escaped  the  comparatively 
feeble  powers  of  his  microscope.  He  described  the  normal  tonsils 
as  "Balg-Driisen,"  i.  e.,  closed,  ductless  glands  developed  in  the 
walls  around  the  depressions  in  the  mucosa.''  Much  contention 
arose  as  to  their  nature.  Henle  (1.  c),  Sappey,^  Sachs,'' and  others 
regarded  them  as  true  acinous  glands,  the  lymph  nodes  being  the 
acini  and  the  invagination  of  the  epithelium  we  call  lacunte  being 
regarded  as  ducts.  One  may  see  in  the  plates  of  Sachs  the  errors 
into  which  this  school  fell.  Sappey,  in  a  later  edition  of  his  great 
work,  failed  to  repeat  this  explanation  of  the  tonsils.  Briicke  had 
also  declared  the  tonsils  were  simply  lymph  glands,  and  Billroth"' 
called  them  follicular  glands.  Although  the  latter  thus  agreed 
with  Kolliker  and  Gerlach  in  properly  regarding  them  as  part  of 
the  lymphatic  system  and  related  to  the  jNIalpighian  corpuscles 
of  the  spleen,  their  conception  of  them  was  that  the  follicles,  or,  as 
we  call  them,  the  nodes,  were  really  closed  sacs  holding  grumous 
material,  the  round  cells  being  apparently  held  in  solution.     The 

'  Histoire  dcs  Tissues,  in  the  Encycloprdie  Anatomique,  Vol.  VI,  Paris,  1843. 

2  The  Physiological  Anatomy  and  Physiology  of  Man,  Todd  and  Bowman,  Vol. 
I,  Chap.  XIV,  p]).  406-426,  iJondon,  1S4.').  Also  to  be  found  in  The  Collected 
Papers  of  8ir  W.  liowman,  London,  1892. 

■''  1.  c.  II.     The  second  volume  was  not  published  until  1856. 

^  Handbuch  der  Gewebelehre,  1852. 

^  Handbuch  der  Eingeweidelehre  des  Menchen.     Braunschweig,  1866. 

*  ]\Iikrosko])ische  Anatomie,  oder  Gewebelehre  des  Aleiichen,  Leipzig,  II,  2, 
18.52. 

"  Huxley:  (Quarter!}'  .Journal  of  Microscopic  Science,  Loudon,  1S,")4,  11,  \).  82, 
who  translated  Kolliker 's  work  into  I^nglish,  declared  in  his  luminous  language: 
"  iSo  far  as  its  structure  is  concerned  in  fact,  the  tonsil  exactly  represents  a 
lymphatic  gland,  developed  around  a  diverticulum  of  the  pharj-ngeal  mucous 
membrane." 

»  Trait6  d'Anatomie,  Paris,  18.57,  III,  p.  43. 

9  Midler's  Archiv  f.  Anat.,  Leipzig,  18.59,  p.  196. 

'"  Beitriige,  zur  path.  Histologic,  Berhn,  1858. 


HORACE  GREEN  201 

finer  intercellular  structure  was  vet  to  be  elucidated  bv  the  investi- 
gations  of  His  in  1862,  and  the  curious  arrangement  of  lymphoid 
tissue  around  the  juncture  of  the  food  and  air  passages  was  pointed 
out  by  Waldeyer  in  1884/  and  "Waldeyer's  Ring"  is  now  a  well- 
known  but  as  yet  little  understood  apparatus. 

Tonsillotomies. — The  structure  of  the  faucial  tonsils,  therefore, 
had  been  largely  elucidated  before  the  development  of  the  specialty 
of  laryngology,  and  the  same  may  be  said  of  their  abscission,  which 
indeed  we  have  seen  full\'  described  in  the  very  earliest  of  medical 
annals.  ]\Iiddel(lorpf  already  described-  his  method  of  ablation 
by  means  of  the  galvanocautery  snare.  Before  this  the  original 
forms  of  the  tonsillotome  now  in  use  had  been  devised.  The  incep- 
tion of  the  jMackenzie  tonsillotome  may  be  seen  on  referring  to 
Bell's  "System  of  Surgery,"  published  in  1791  (\'ol.  Ill,  p.  87). 
This  was  modified  in  1828  by  Philip  Syng  Physick,''  who  first  used 
it  for  amputating  the  uvula,  adapting  it  subsequently'  to  the 
tonsils,  and  using  a  forceps  to  drag  them  through  the  loop  of  his 
instrument. 

Out  of  this  grew  another  device  for  the  same  purpose.  Fahn- 
stock^  four  years  later  described  the  instrument  which  was  adopted 
and  modified  somewhat  in  France,  and  is  now  known  under  his 
name  or  that  of  ]\Iatthieu. 

Horace  Green. — One  of  the  striking  incidents  in  the  history  of 
laryngology  w^as  the  storm  aroused  in  America,  in  the  decade 
preceding  the  announcement  of  Garcia,  by  the  persistent  claims 
of  Horace  Green.  The  question  as  to  whether  it  was  possible  to 
introduce,  j^er  vias  naturales,  a  probe  into  the  box  of  the  larynx 
seems,  on  the  eve  of  the  discovery  of  the  laryngoscope,  to  have 
been  the  most  inconsequential  of  contentions,  yet  it  excited  in 
New  York,  and  to  some  extent  in  London  and  Paris,  the  bitterest 
feelings  of  resentment,  anger,  and  opposition.  The  only  explanation 
of  the  importance  which  was  at  the  time  attached  to  this  contention 
would  seem  to  have  been  the  latent  idea,  that  if  they  once  succeeded 
in  performing  this  feat  of  legerdemain,  all  the  ills  of  the  larynx 
would  be  cured.  But  if  one  may  conjecture  that  this  was  the  idea 
which  lent  importance  to  the  controversy  fifty  years  ago,  it  is 
impossible  to  fathom  the  reason  which  has  occasionally  led  writers 
since  then  to  regard  this  episode,  in  the  history  of  laryngology, 
as  anything  more  than  a  lamentable  example  of  how  coteries  of 
medical  men  will  insult  one  another,  and  transgress  the  bounds 
of  decency  in  their  discussion  of  a  tri\ial  matter.  We  have  seen 
how  Hippocrates  referred  to  passing  tubes  into  the  air  passages, 

'  Deutsche  ined.  Woch.,  May  15,  1884,  X,  p.  313. 

2  Die  Galvanocaustic,  Breslau,  1854. 

'  American  Journal  of  (lie  Medical  Sciences,  1828,  Vol.  I,  p.  262. 

M.  c,  Vol.  11,  p.  11(5. 

5  American  Jour.  Med.  Sc,  1832,  Vol.  XI,  p.  249. 


202  THE  PRE-LARYNGOSCOPIC  ERA 

and  how  it  is  mentioned  in  all  pre-Renaissance  medical  writers. 
We  shall  see  later  in  the  history  of  intuljation  how  Desaiilt,  Loiseau, 
Bouchut,  fully  demonstrated  the  possibility  of  introducing  instru- 
ments into  the  larynx  from  above.  Horace  Green  was  persecuted 
and  reviled  for  claiming  he  «mld  perform  this  operation,  but  this 
isonly  a  part  of  the  st()ry.J  He  laid  himself  open  to  criticism  by 
"^ainTihgThat  by  llitTprocedure  he  could  a])ply  medicaments  which 
would  cause  the  cure  of  various  pulmonary  and  laryngeal  lesions, 
which  the  same  vastly  more  accurate  manoeuvers,  guided  by  the 
laryngoscope,  are  today  unable  to  accom])lish.  His  pathology, 
Resting  oTT  the  half  comprehended  ideas  of  Louis,  was  so  erroneous 
/and  crude  as  to  secure  no  support  from  his  more  scientific  colleagues. 

Very  frequently  a  new  triumph  of  dexterity  or  invention  in  any 
department  of  surgery  leads  to  the  erroneous  assumption  that 
because  a  difficulty  of  technique  has  been  o\ercome,  a  new  era 
in  surgical  therapy  has  been  inaugurated. 

As  early  as  ISIS  Bretonneau^  had  carried  a  probang  over  the 
aryteno-epiglottic  ligaments  and  expressed  fluids  from  the  sponge 
at  this  point,  but  Trousseau  denied  that  the  interior  of  the  larynx 
was  reached  by  him. 

Trousseau  and  Belloc  in  their  great  work,  published  in  French 
first  in  1S37  and  translated  into  English  in  1841,  described  a 
method  of  making  applications  to  the  larynx  which  leaves  us  also 
in  considerable  doubt  if  they  exer  really  succeeded  in  placing  any 
medicament  in  the  larynx  itself.  Their  own  doubts  as  to  this  are 
emphasized  in  the  skepticism  which  Trousseau  later  evinced 
toward  the  assertions  of  Green,  who,  however,  was  finally  acknowl- 
edged by  him  to  have  succeeded  in  entering  the  larynx.  Horace 
Green,  in  1840,  published  his  "Treatise  on  Diseases  of  the  Air 
Passages,  Comprising  an  Inquiry  into  the  History,  Pathology, 
Causes,  and  Treatment  of  Those  Affections  of  the  Throat  Called 
Bronchitis,  Chronic  Laryngitis,  Clergyman's  Sore  Throat,  Etc." 
Li  1S4U  he  had  reported  a  number  of  cases  of  laryngeal  and  bronchial 
disease  to  the  New  York  Medical  and  Surgical  Society  as  cured 
by  intralaryngeal  applications.  His  statements,  while  finding 
some  supi)ort,  were  received  with  incredulity  by  a  large  number 
of  his  hearers.  It  was  thought  and  persistently  argued  that  it  was 
impossible  in  practice  to  introduce  instruments  into  the  larynx. 
He  had  made  his  first  successful  attempt  in  1S38,  a  year  after  the 
])ablication  of  Trousseau  and  Belloc's  work  in  France.  He  was 
subsequently  charged  with  having  derived  his  ideas  from  this  book 
and  having  failed  to  acknowledge  it.  His  favorite,  almost  his  sole, 
local  application  was  a  40-80  grains  to  the  ounce  solution  of  nitrate 
of  silver.  His  laryngeal  applicators  had  practically  the  same  curves 
as  those  now  in  use.    A  number  of  prominent  medical  men  testified 

1  Traits  de  la  Diphthc^ric 


THE  LARYNGOSCOPE  203 

to  the  accuracy  of  his  statements  as  to  the  practicability  of  intra- 
laryngeal  applications.  Immediately  the  book  met  with  the 
bitterest  reception  on  the  part  of  the  medical  press. ^ 

It  would  be  profitless  to  follow  the  history  of  all  the  bitter  con- 
troversy of  the  time.  He  was  attacked  with  savage  malignity,  but 
vulnerable  as  were  many  of  his  other  ideas,  he  nevertheless  suc- 
ceeded finally  in  proving  that  he  could  enter  the  larj'nx  with  his 
applicator.  In  this  claim  he  was  firmly  supported,  in  the  end,  by 
the  leaders  of  the  profession  in  New  York,  and  although  even  as 
late  as  1855  Erichsen,-  in  London,  while  admitting  that  the  pro- 
bang  might  be  carried  to  the  vocal  cords,  decided  that  it  could  not 
be  introduced  further.^  Xeverthless  in  the  course  of  the  bitter 
contest  Dr.  Green  was  compelled  to  resign  from  one  of  the  medical 
societies  in  New  York  and  was  even  threatened  with  expulsion 
from  the  Academy  of  INIedicine.  The  matter  was  fully  discussed 
there  in  1855,  and  an  unfavorable  report  was  made  by  a  committee 
appointed  to  investigate  his  assertions.  This  was,  however,  laid 
on  the  table.  He  finally  fully  established  his  claims  to  be  able  to 
enter  the  larynx,  but  he  did  not  succeed  in  proving  the  further  claim 
of  his  ability  to  inject  medication  into  the  bronchial  tubes  and 
tubercular  cavities  of  the  lungs.  Green  eventually  somewhat 
receded  from  this  position,  saying  that  he  could  inject  it  below  the 
trachea.  He  grossly  exaggerated  the  efficacy  of  these  topical 
applications,  saying  that  he  had  produced  thereby  astonishingly 
ameliorating  effects  with  his  nitrate  of  silver. 

Doubtless  in  many  cases  he  was  self-decei^'ed  by  a  faulty  diagnosis 
and  by  his  superficial  knowledge  of  pathological  anatomy.  There 
is,  however,  no  doubt  that  he  greath'  benefited  manv  cases  of 
simple  chronic  catarrhal  inflammations  of  the  pharynx  and  larynx, 
and  his  success  in  obtaining  a  large  clientele  doubtless  had  some- 
thing to  do  with  the  jealousy  of  his  confreres.^ 

THE  LARYNGOSCOPE. 

We  have  now  passed  in  review  events  of  interest  to  us  in  the 
first  half  of  the  wonderful  centur\'  just  completed.  Before  we 
proceed  further  and  enter  directly  upon  that  era  in  which  laryn- 
goscopy created  a  new  field  for  scientific  endeavor  and  observation, 
let  us  not  forget  the  advance  in  that  intellectual  evolution,  that 

1  Something  of  this  maj'  be  found  in  the  Boston  Medical  and  Surgical  Journal, 
Dec.  IG,  1846,  XXXV,  ]>.  ;]!)2,  et  scq. 

2  Lancet,  Nov.  24  Dec.  1,  185.").  11,  pp.  489,  518. 

3  Bull,  de  I'Acad.  Imper.  de  IMedecine,  1858,  Vol.  24,  p.  101.  Trousseau 
admitted  that  to  Horace  Green  belongs  the  honor  of  having  methodically  and 
systematically  treated  diphtheria  when  it  occupies  the  larynx,  by  caustics 
introduced  by  means  of  a  little  sponge.  .\  little  later  Loiseau  carried  solutions 
of  tannin,  etc.,  into  the  larynx. 

^  For  a  list  of  the  works  of  Horace  CJreen,  see  his  obituary-  notice  in  the  New 
York  Medical  Journal,  Jan.,  1867,  IV,  j).  ;U6. 


204  THE  LARYNGOSCOPE 

most  important  and  alI-]HT\  adiiiu'  eleiiuMit  in  the  liistory  of  ciA"iliza- 
tion,  which  the  (iermans,  after  their  wont,  have  rolled  together 
in  one  word  and  called  the  "Zeit-Geist."  After  the  French  Revolu- 
tion there  was  hardly  an  obstacle  in  the  world  to  the  advance  of 
science — none  except  the  bijjoted  hut  almost  impotent  sentiment 
of  the  Church.  The  fasjot,  the  rack,  and  the  hoot,  ])rison  and  exile, 
had  long  since  })assed  away  from  the  horizon  of  possibilities  in 
the  personal  ])r()spect  of  the  man  of  Science.  From  the  burning 
of  Bruno  and  the  degradation  of  Galileo  to  Wilberforce's  undignified 
and  maladroit  taunt  against  the  Darwinians  at  Oxford,  a  period  of 
scarcely  two  hundred  and  fifty  years  had  elapsed.  It  needed  not 
Iluxlev's  cutting  rejoinder  to  remind  the  world  that  ecclesiasticism 
was  no  longer  an  efficient  engine  of  intellectual  tyranny. 

The  Laryngoscope  of  Bozzini. — The  century  had  hardly  opened 
when  we  find  the  idea  existent  that  it  might  be  possil)le,  by  means 
of  a  mirror,  to  see  into  the  larynx.^  Bozzini  seems  to  have  drawn 
on  himself  an  undeserved  amount  of  criticism  by  the  publication, 
in  1807,  of  a  brochure,^  describing  a  double  cannula  with  a  mirror 
placed  at  an  angle  at  the  end,  which  was  supposed  to  transmit 
light  through  one  compartment,  and  reflect  it  from  the  mirror  on 
to  the  parts  examined,  whose  image,  received  on  the  mirror,  was 
reflected  back  to  the  eye  through  the  other  compartment.  It  was 
supposed,  singular  to  say,  that  the  light  ])assing  in  would  interfere 
with  the  perception  of  the  reflected  image  if  one  tube  was  used. 
A  wax  candle  with  a  reflector  behind  it  supplied  the  illumination. 
This  instrument  was  used  successfully.  With  it  and  others,  Bozzini 
claimed  to  be  able  to  inspect  the  various  canals  of  the  body,  among 
them,  the  larynx.  Of  course  this  contrivance  was  too  imperfect  to 
attract  any  attention  to  the  idea,  but  the  invention  of  Babington, 
and  that  of  Cagniard  de  la  Tour,  were  practically  the  present  instru- 
ment. Fxliibited  before  scientific  bodies  it  is  singular,  l)ut  instruc- 
tive, that  these  should  not  have  attracted  the  notice  whicli  thirty 
years  later  was  gi\"en  to  Garcia's  iuNcntion. 

Babington. — In  1829  Benjamin  Babington  presented  to  the 
Ilunterian  Society^  "an  oblong  piece  of  looking  glass,  set  in  silver 

1  In  Mackenzie's  early  account  of  the  hi.stoi\y  of  llie  laiyngoscope  he  committed 
the  error  of  referring  to  Celsus  as  having  been  familiar  with  the  use  of  dentists' 
mirrors.  He  evidently  mistook  the  word  sfjecillum,  meaning  a  probe,  in  De 
Medicina,  VII,  c.  XII,  for  si)eculum,  meaning  a  mirror.  He  wa.s  also  wrong  in 
suppo.sing  that  Levret,  in  the  eighteenth  century,  had  any  glimmer  of  the 
possibilities  of  the  idea  of  laryngoscop\'  in  recommending  a  polislied  steel  tongue 
depressor  in  examining  the  i)harynx. 

Vid.  Levret;  Observations  sur  la  Cure  Hailicale  de  Plusieurs  Polypes  de  la 
Matrice,  de  la  Gorge,  et  du  Nez.,  Paris,  1749. 

2  Der  Lichtleiter  od(>r  Beschreil)ung  einer  einfachen  \'orrichtung  und  ihrer 
Anwendung  zur  iM'leuclitung  innercr  Ilolilen  und  Zwischenraume  des  lebenden 
animahschen  Korpers,  von  Philip  Bozzini,  der  Medizin  und  Chirurgie  Doctor, 
Weimar,  18(J7. 

I  am  indebted  to  other  sources,  chiefly  Morell  Mackenzie's  works,  for  an 
account  of  this  brochure. 

3  London  Medical  Gazette,  1829,  III,  p.  555. 


SELLIGUE  205 

wire,  with  a  long  shank.  The  reflecting  portion  was  to  be  held 
against  the  palate,  whilst  the  tongue  was  held  down  by  a  spatula." 
The  doctor  proposed  to  call  this  contrivance  a  Glottoscope.^ 

Cagniard  de  la  Tour. — Fournie  says'^  that  in  1825  M.  Cagniard 
de  la  Tour  introduced  into  the  back  part  of  his  own  throat  a  little 
mirror,  hoping  that  by  the  aid  of  the  solar  rays  and  of  a  second 
mirror  he  could  see  the  epiglottis  and  ex  en  the  glottis,  but  he  was 
only  partly  successful. 

Senn. — There  is  still  another  record  of  this  date,  which  is  interest- 
ing in  connection  with  the  foregoing  as  illustrating  how  the  idea 
was  hovering  in  the  air  long  before  Garcia.  Senn,^  in  1827,  tried  to 
use  a  small  mirror  in  the  pharynx  to  see  the  parts  below.  He  used 
no  illumination  and  supposed  his  failure  was  due  to  the  small  size 
of  the  mirror.  Again  we  find  a  great  London  surgeon,  who  appre- 
ciated some  of  the  possibilities  of  such  an  instrument  in   1837. 

Liston. — Liston^  declared:  "The  existence  of  this  swelling  (of 
the  laryngeal  mucosa)  can  often  be  ascertained  .  .  .  by  means 
of  a  speculum;  by  such  a  glass  as  is  used  by  dentists,  on  a  long 
stalk,  previously  dipped  in  hot  water,  introduced  with  its  reflecting 
surface  downward  and  carried  well  back  into  the  fauces,  a  view- 
may  often  l)e  had  of  the  parts." 

Baumes. — Baumes,  in  1838,^  exhibited  at  the  Medical  Society  of 
Lyons  a  mirror  the  size  of  a  two-franc  piece,  which  he  described  as 
being  very  useful  for  examining  the  posterior  nares  and  larynx. 

Much  more  earnest  but  scarcely  so  successful  were  the  eft'orts 
of  Trousseau  and  Belloc  to  see  the  parts  intra  vitam,  with  which 
their  work  on  laryngeal  phthisis  in  1837  was  concerned.  I  may 
quote,  directly  from  them,  their  own  experience  and  that  of  others 
I  have  not  thus  far  mentioned. 

Selligue. — "For  several  years  we  have  been  occupied  with  the 
construction  of  a  speculum  laryngis.  The  one  of  AL  Selligue  is 
known.  He  is  a  very  ingenious  mechanic,  who,  aft'ected  himself 
with  laryngeal  phthisis  from  which  he  had  entirely  recovered, 
made  for  his  physician  a  speculum  with  two  tubes,  of  which  one 
served  to  carry  the  light  to  the  glottis,  and  the  other  served  to 
carry  back  to  the  eye  the  image  of  the  glottis  reflected  in  a  mirror 
placed  at  the  guttural  extremity  of  the  instrument.     .     .     .     The 

1  According  to  Mackenzie,  Babington's  patient  sat  with  his  back  to  the  sun, 
the  rays  of  which  were  reflected  into  his  throat  by  an  ordinary  liand  mirror. 
In  Mackenzie's  book,  The  Use  of  the  Laryngoscope,  London,  1865,  p.  14,  the 
laryngeal  mirror  of  Babington  is  illustrated,  but  in  the  original  notice  here  cited, 
there  is  no  reference  to  the  method  of  illumination,  excei)t  that  a  strong  light 
is  necessary. 

-  Phvsioiogie  de  la  Voix,  Paris,  1866,  p.  352 — quoting  from  the  Journal  de 
rinstitut.,  1825,  No.  225. 

'  Jour,  des  Progres,  1829,  p.  231.    Note  (quoted  by  Mackenzie  1.  c.)- 

*  Practical  Surgery,  by  Robert  Liston,  London,  1837,  p.  350. 

*  Compte  Rendu  des  Travaux  de  la  Societ6  de  Medecine  de  Lyons,  1836-1838, 
p.  62. 


206  THE  LARYNGOSCOPE 

use  of  this  is  very  difficult,  and  there  is  only  about  one  patient  in 
ten  who  can  bear  its  introduction.  Indeed,  it  is  of  a  volume  which 
occupies  the  space  comprised  between  the  free  border  of  the  velum 
palate  and  the  su])erior  surface  of  the  tongue."  A  similar  instru- 
ment, the  description  of  which  Ave  may  note  corresponds  with  that 
of  Bozzini,  was  made  for  them,  but  so  unsuccessful  were  they  with 
it  they  denied  it  was  possible  for  Bennati^  to  see  the  jjlottis  with 
tlie  instrument  of  Selligue.  "He  might  have  seen  the  epiglottis 
or  the  superior  opening  of  the  larynx,  but  as  for  the  glottis,  it  is 
situated  at  such  a  depth  and  in  such  a  manner  that  it  is  impossible 
to  see  it  with  the  speculum  even  in  the  cadaver,  while  the  irritation 
of  the  pharynx  in  the  li\e  subject  renders  it  still  more  inaccessible, 
even  in  those  who  are  most  accustomed  to  it."  This  emphatic 
expression  of  a  negative  opinion  as  to  the  ])erformances  of  others, 
was  characteristic  of  the  man  who  later  in  life,  at  first  obstinately 
refused  credence  to  the  practicability  of  Green's  topical  applica- 
tions, and  Bouchut's  intubation  of  the  larynx. 

Warden. — Adam  Warden^  suggested  the  use  of  refracting  prisms 
to  carry  the  light  and  the  line  of  vision  to  parts  witliin  the  larynx, 
the  ear  and  the  vagina,  through  variously  devised  cannulte.  lie 
claimed  that  in  one  case  he  was  able  to  see  the  pathological  condition 
of  the  larynx.^ 

This  idea  later  also  occurred  to  Ephraim  Cutter  in  America,* 
about  the  time  larAugoscopv  became  elsewhere  an  accomplished 
fact. 

Avery. — ^Mackenzie  (1.  c,  p.  22)  gives  a  full  description  and  an 
illustration  of  the  laryngoscope  of  Avery  invented  in  London  in 
1844.  A  small  lamj)  attached  to  a  head-piece  was  worn  on  the  fore- 
head with  a  reflector  behind  it.  A  speculum  similar  to  Bozzini's, 
except  with  a  single  tul)e,  was  used  to  hold  the  reflecting  mirror. 

The  collection  of  these  notes  seems  to  make  a  respectable  pre- 
laryngoscopic  history  of  the  laryngoscope.  How  completely  the 
idea,  dwelling  in  the  minds  of  men,  had  failed  to  take  root,  is  to  be 
noted  in  the  remark  of  Friedreich  (1854),  I  have  quoted,  regarding 
the  impracticability  of  extending  to  tlie  larynx  any  method  of 
physical  examination. 

Manuel  Garcia.— These  are  the  brief  words  with  which  Manuel 
Garcia,  in  ISoo,  explained  his  device  for  examining  the  larynx: 
"The  pages  which  follow  are  intended  to  describe  some  observations 
made  on  the  interior  of  the  larynx,  during  the  act  of  singing.  The 
method  which  I  have  adopted  is  very  sinij)le.  It  consists  in  placing 
a  little  mirror,  fixed  on  a  long  handle  suitably  bent,  in  the  throat 

1  Bennati,  in  a  footnote  to  the  3d  edition  of  liis  llccherches  sur  la  Yoix 
Huinaine,  describes  the  instrument  here  referred  to. 

-  London  Medical  Gazette,  n.  s.,  Vol.  II,  1S44,  p.  250. 

•''  Monthly  Journal  of  Medical  Sciences,  London,  1S45,  V,  p.  5.52. 

••  A  contribution  to  the  History  of  Laryngo.scopy,  by  Louis  Elsberg,  M.D. 
Archives  of  Laryngology,  1883,  Vol.  IV,  p.  122. 


DIFFICULTIES  OF  TECHNIQUE  207 

of  the  person  experimented  on,  against  the  soft  palate  and  uvula. 
The  party  ought  to  turn  himself  toward  the  sun,  so  that  the 
luminous  rays,  falling  on  the  little  mirror,  may  be  reflected  on  the 
larynx.  If  the  observer  experiment  on  himself  he  ought,  by  means 
of  a  second  mirror,  to  receive  the  rays  of  the  sun  and  direct  them 
on  the  mirror  which  is  placed  against  the  uvula. "^ 

Garcia  was  entirely  unaware  of  the  previous  attempts  to  accom- 
plish his  purpose  with  devices,  some  of  which  were  identical  with 
his  own.  His  invention,  great  in  utility  as  it  was  in  the  hands  of 
medical  men,  was  merely  an  incidental  contrivance  in  those  of  the 
earnest  teacher  of  singing,  who  desired  to  see  the  apparatus  which 
produced  the  sounds  he  was  endeavoring  to  train  into  harmony 
and  the  remainder  of  his  communication  is  largely  devoted  to  the 
conclusions  he  drew  from  what  he  saw  in  his  own  throat  of  the 
various  laryngeal  movements  during  the  act  of  musical  phonation. 
The  announcement,  therefore,  was  chiefly  a  demonstration  of 
autolaryngoscopy. 

Garcia  was  called  the  Father  of  Laryngoscopy  and  in  the  sense 
that  his  independent  discovery  of  the  laryngoscope  resulted  in  its 
utilization  in  founding  the  specialty  of  laryngology  the  title  is 
deserved.  Yet  we  have  seen  how  long  before  him  the  conception 
of  laryngoscopy  and  the  actual  invention  of  the  laryngoscope  had 
preceded  his  own.  He  had  the  rare  fortune  to  live  long  enough 
to  see  the  enormous  consequences  of  the  attention  which  his  studies 
attracted.  He  lived  to  be  more  than  a  hundred  years  old,  dying 
in  1906  in  his  102d  year.-  In  1905  delegations  of  laryngologists 
from  all  parts  of  the  civilized  world  gathered  in  London  on  the 
occasion  of  his  centenary^  to  do  him  honor. 

Difficulties  of  Technique. — The  crux  of  the  difficulties  which  had 
hitherto  prevented  the  utilization  of  this  device  which  had,  as 
we  have  seen,  been  so  many  times  proposed,  is  evidenced  in  the 
notice  of  Garcia's  communication  which  appeared  in  Paris.*  "M. 
Garcia  has  the  faculty  of  supporting  in  the  pharynx  and  at  the 
isthmus  of  the  fauces  the  prolonged  contact  of  foreign  bodies  with- 
out provoking  in  him  efforts  at  vomiting."  Commenting  on  this 
the  editor  said:  "As  for  the  ingenious  procedure  by  which  he  was 
able  to  see  the  glottis  in  function,  I  hope  indeed  soon  to  be  in  a 
position  to  repeat  it  myself."  This  latter  remark  is  an  early  hint 
as  to  the  interest  aroused  by  the  announcement  that  it  was  possible 
to  see  a  puzzling,  interesting,  familiar,  but  hitherto  invisible 
physiological  phenomenon,  but  it  bore  no  trace  of  any  tliought 

1  Observations  on  the  Human  Voice,  bv  Manuel  Garcia,  Esq.  Received 
March  22,  185.5;  Procpedinfts  of  the  Royal  Society  of  London,  1855,  VII,  p.  399. 

-  Internat.  Centralblatt  fiir  Larj-ngologie,  etc.,  190(),  XXII,  p.  281. 

^  Ibid.,  1905,  XXI,  p.  91. 

^  M.  Segond:  Gazette  Hebdomadaii-c  de  Medecihe  et  dc  Cliirurgie,  Paris 
Nov.  16,  1855,  II,  No.  46,  p.  816. 


208  THE  LARYNGOSCOPE 

as  to  the  vast  possibilities  in  the  way  of  studying  pathological 
])li('ii()in('iia. 

Ludwig  Tiirck. — It  is  thus  that  Ludwig  Tiirck  relates^  how  his 
attention  was  directed  in  Vienna  to  the  matter  in  1S57:  "Half 
through  accident,  without  knowing  of  my  predecessors,  I  came  to 
the  idea  of  using  a  small  mirror  for  the  investigation  of  laryngeal 
disease.  First,  as  I  was  showing  Professor  Ludwig  the  internal 
laryngeal  structures  of  a  patient  in  my  hospital  di\"ision,  I  learned 
of  (iarcia's  investigations."  From  that  it  would  appear  that 
Tiirck  had  himself  invented  an  instrument  before  he  knew  of 
Garcia's.  Others  declare  that  Garcia's  communication  was  on 
his  hands  before  he  came  upon  the  idea.  However  this  may  have 
been,  certain  it  is  that  Tiirck  had  workefl  at  the  problem  before 
(V.crmak  took  it  up.  The  latter,  however,  preceded  him  in  the 
public  announcement  of  his  studies. 

Johann  Czermak. — In  ]\Iarch,  1858,  there  appeared  a  i)ul)lication2 
upon  the  laryngeal  mirror  in  one  of  the  Menna  medical  papers. 
It  was  by  Professor  Czermak,  who  said  that  Tiirck  some  time 
previously  had  been  attempting  to  use  some  of  Garcia's  instruments. 
Czermak  borrowed  some  mirrors  of  Tiirck  for  the  same  purpose, 
and  his  paper  consisted  only  of  some  remarks  on  his  experience, 
but  he  urged  all  physicians  to  make  a  trial  of  them.  He  said  that 
Tiirck  and  Garcia  used  sunlight,  but  he  made  use  of  lamplight  and 
advised  the  employment  of  a  "large  perforated  concave  mirror 
for  reflecting  either  the  sun  or  artificial  light."  Subsequently  he 
very  correctiv  asserted^  that  })ut  for  this  iuAention  of  the  reflecting 
mirror,  laryngoscopy  would  have  been  "a  dead-born  child."  He 
urged  in  his  first  communication  that  by  persistent  practice  diffi- 
culties in  the  technique  may  be  overcome,  Czermak's  first  device 
for  fixing  the  head  mirror  seems  to  have  been  to  hold  the  frame  of 
the  mirror  between  the  teeth,  Semeleder  adapting  it  to  a  spectacle 
frame  in  1858.  Whatever  may  have  preceded  this,  it  is  evident 
on  a  perusal  of  the  literature  of  the  subject  at  this  period  what  an 
impulse  Czermak's  brii^f  notice  gave  the  whole  matter.  It  aroused 
the  languid  interest  of  others,  and  soon  excited  the  active  resent- 
ment of  Tiirck.  Less  than  two  weeks  after  this  first  communica- 
tion in  a  medical  journal,  Czermak  gave  a  ])ul)lic  demonstration 
of  the  use  of  the  laryngoscope.'*  At  this  meeting  Tiirck  was  present 
and  claimed  priority  as  the  first  to  employ  it  for  diagnostic  purposes.^ 
This  Czermak  admitted. 

'  Klinik  dcr  Krankheitcn  dos  Kehlkopfes,  Wien,  ISfiG. 

^  Ueber  don  Kchlkopfsiiicgel,  von  Prof.  Joh.  Czermak;  Wiener  med.  Wochen- 
schrift,  March  27,  18.58,  VIII,  No.  V.i,  p.  196. 

^  Der  Kclilkopl'spiegel,  2  Aufl.,  Leipzifi,  1863. 

^  Zeitscliiit't  (ler  Gesellfschaft  dcr  Aerzte,  Sitzungsbericht;  Sect.  f.  Phv.si- 
ologie  und  Pathologie,  No.  17,  April  26,  1858,  Jahrg.,  XIV,  p.  271. 

^  Sec  also:  A.  o.  Beilage  zu  No.  16,  dcr  Wiener  medizin.  Woehenschrift, 
April  17,  1858,  VII,  p.  265. 


TURCK  AND  CZERMAK  IN  FRANCE  209 

Soon  followed  Tiirck's  own  publications.^  Jealousy  and  strife 
soon  began  between  the  two  men,  and  the  history  of  it  is  an  undig- 
nified record,  the  relation  of  which  would  serve  no  good  purpose 
but  to  exhibit  the  folly  of  it  and  the  harm  such  incidents  do  to  the 
posthumous  fame  of  otherwise  distinguished  men.^ 

Rhinopharyngoscopy.^ — Czermak  soon  opened  up  another  region 
in  the  throat  to  examination.  He  turned  his  mirrors  upward  and 
demonstrated  the  pharyngonasal  cavity,  in  Buda-Pesth,  July  29, 
1859.^  Very  shortly  after  this,  ^'oltolini  took  the  matter  up*  and 
still  further  developed  the  technique,  abandoning  the  palate 
retractor  used  by  Czermak.  The  latter  in  his  early  attempts  at 
post-rhinoscopy  had  also  attempted  the  use  of  double  mirrors,  one 
placed  at  an  angle  abo\'e  the  other  to  show  the  choanse.  Czermak 
also  introduced  a  mirror  through  a  tracheal  opening  and  demon- 
strated the  under  surface  of  the  vocal  cords.  The  mirrors  at  first 
and  for  long  afterward  varied  in  shape  and  size,  many  having 
bent  handles.  There  were  many  subsidiary  devices  which  com- 
plicated, but  did  not  improve  the  technique,  and  early  in  the 
history  of  laryngoscopy  we  may  note  the  old  idea  of  Aranzi  l\y 
which  sunlight  was  admitted  through  a  hole  in  a  shutter  of  a  dark 
room  and  allowed  to  fall,  either  directly  or  through  a  water  bottle, 
into  the  nostrils  or  mouth  of  a  patient.  This  was  rendered  more 
efficient  by  the  use  of  a  deflecting  or  reflecting  mirror.^ 

Voltolini''  invented  an  apparatus  for  the  manufacturing  and 
burning  of  oxygen  gas  to  be  used  in  an  incandescent  light  for 
examining  the  ear  and  larynx  with  Garcia's  instrument. 

Turck  and  Czermak  in  France. — By  the  profession  in  general,  the 
new  instrument  at  first  was  looked  upon  with  some  scorn  as  a 
physiological  plaything,  and  the  dispute  as  to  the  priority'  of  its 
use  may  perhaps  have  had  some  beneficial  eft'ect  in  attracting  an 
attention  which  its  merits  could  not  have  efi^ected.  Tiirck  and 
Czermak  carried  their  ideas  and  their  warfare  into  France.  Having 
both  published  separate  brochures  in  German  on  the  use  of  the 
laryngoscope,  Czermak  in  1859,  and  Tiirck  in  1860,  they  republished 
these  immediately  in  French,  and  both  went  to  Paris,  where  they 
gave  public  exhibitions  and  lessons  in  the  new  art.  A  commission 
of  the  Academy  of  Sciences  of  the  Imperial  Institute  of  France 
was  appointed  to  investigate  their  rival  claims.  This  did  not  choose 
to  go  into  the  question  of  ])riority,  but  accorded  them  both  honor- 

1  Zcitsehiift  dcr  K.  K.  Gesell.  tier  Aerzte  zu  Wien,  No.  26,  June  28,  1858, 
Jahrg.,  XIV,  p.  401. 

2  Lists  of  the  numerous  contributions  of  Tiirck  and  Czermak  to  the  literature 
of  the  subject  may  be  found  appended  to  their  hiter  more  vohmiinous  works. 

'  Der  Kehlkopfspiegel,  etc.,  1860,  von  Joh.  Czermak,  also  Deutsche  Klinik, 
Berlin,  No.  21,  18()(),  XII,  p.  202.     Die  Besichtigung  der  Tuba  Eustachii,  etc. 

*Vircho\v's  Arcliiv,  Berlin,  ISGl,  XXI,  p.  45. 

*  See  among  others  Stork:  Zeitsch.  der  K.  K.  Gesell.  der  Aerzte  zu  Wien, 
No.  46,  p.  721,  1859. 

6  Virchovv's  Archiv,  1859,  XVII,  p.  193. 
14 


210  THE  LARYNGOSCOPE 

able  mention  (March  21,  1861)  for  the  services  they  had  rendered 
science  in  the  introthiction  of  the  laryn<2;oscope.  The  committee 
suggested  tliat  1200  francs  for  each  he  added  to  this  honor. 

Clinical  Use  of  Laryngoscopy. — While  (V.crniak  had  remarked 
upon  some  pathological  conditions,  he  attributed  the  first  studies 
in  this  field  to  his  pupil,  Semeleder,  who  in  1858,  published^  an 
account  of  some  pathological  conditions  of  the  epiglottis  and  of 
the  tongue.  Stork,  Tiirck,  and  Gerhardt,  in  the  same  year  and  the 
next  began  their  numerous  contributions  to  the  literature  of  intra- 
laryngeal  pathology.  In  this  Tiirck  was  especially  prolific-  All 
these  earlier  works  of  Tiirck  were  in  some  form  soon  translated 
into  French  and  English.  AVhatever  may  have  been  his  merit 
as  to  the  inception  of  the  idea  of  laryngoscopy,  he  was  foremost 
in  the  spread  of  the  knowledge  of  disease  re\ealed  by  it. 

Intralaryngeal  Applications. — For  the  most  part  his  idea  of 
pathology,  especially  pertaining  to  tuberculosis,  conformed  to 
the  principles  of  Rokitansky.  He  described  the  appearances  in 
lupus,  diphtheria,  syphilis,  tumors,  and  (rdema  of  the  larynx. 
Stork,  in  lSo9,  in  an  article  on  the  technique  of  laryngoscopy  spoke 
of  making  laryngeal  applications  of  nitrate  of  silver  with  the  aid 
of  the  laryngoscope.  Thus  early  was  the  question  which  agitated 
Horace  Green  and  his  adversaries  conclusively  settled  without 
controversy.  Czermak  also  claimed  to  have  made  applications  of 
caustics  and  other  drugs  to  the  larynx  under  the  guidance  of  the 
laryngoscope  as  early  as  1859. 

The  Spread  of  Laryngoscopy. — The  use  of  the  laryngoscope  quickly 
spread  in  the  large  cities  of  other  lands.  In  London  P.  C.  Price, 
apparently  unacquainted  with  Garcia's  communication  to  the 
Royal  Society  four  years  previouslv,  published^  an  account  of  a 
steel  mirror  which  was  to  be  used  in  examining  the  back  part  of 
the  tongue  and  the  epiglottis.  In  the  Medical  Times  and  Gazette, 
August  4,  1860,  there  is  a  short  editorial  note  mentioning  the 
investigations  of  Tiirck  and  Czermak,  and  stating  inaccurately 
that  the  mirrors  used  were  similar  to  those  invented  ten  years 
before  by  IMr.  Avery. 

Morell  Mackenzie  had  visited  Czermak  in  1859,  and  was  in 
Vienna  during  the  controversy  between  Czermak  and  Tiirck.  On 
his  return  to  London  in  1860,  in  company  with  Gibbs,  Prosser 
James,  and  others,  he  was  foremost  in  the  use  of  the  laryngoscope 
and  the  study  of  the  phenomena  which  it  revealed,  and  in  1863  he 

1  Zeitsch.  der  K.  K.  Gesell.  tier  Aerzte  zu  Wien.,  No.  28,  July,  1858,  Jahrg., 
XIV,  p.  433. 

2  His  contributions  and  tlioso  of  others  are  to  be  found  chieflj'  in  the  Zeitsch. 
der  K.  K.  Gesell.  der  Aerzte  zu  Wien  and  the  AUsenieine  Medizin.  Zeitung 
during  1859  and  1860.  His  brochure,  Praktische  Anloitung  zur  Laryngoscopie, 
Wien,  1860,  is  largely  a  reprint  of  these  pajiers  together  with  a  historical  and 
polemical  dissertation  on  the  subject  of  Laryngoscopy. 

3  The  Lancet,  December  24,  1859,  II,  p.  {)43. 


THE  SPREAD  OF  LARYNGOSCOPY  211 

obtained  the  Jackson  prize  of  the  Royal  College  of  Surgeons  for 
his  essay  on  "The  Pathology  and  Treatment  of  Laryngeal  Disease," 
his  brochure  on  "The  Use  of  the  Laryngoscope  in  Diseases  of  the 
Throat  with  an  Appendix  on  Rhinoscopy"  appearing  in  1865. 

Windsor^  gave  an  account  of  the  history  of  the  laryngoscope 
and  pointed  out  the  promise  of  its  future.  C.  Rauchfuss^  intro- 
duced into  Russia  the  knowledge  of  laryngoscopy  and  intra- 
laryngeal  operations. 

Czermak  and  Tiirck,  as  we  have  seen,  published  their  first  books 
in  France  in  1859  and  1860.  Li  1861  Moura  had  advanced  far 
enough  in  the  new  art  to  publish  a  treatise  on  laryngoscopy,  a 
second  edition  appearing  in  1865.  Czermak  besides  his  stay  in 
Paris  also  visited  London,  as  did  Tiirck.  The  former  also  visited 
many  cities  in  Germany,  and  Tobold,  in  Berlin,  in  1863,  published 
his  "Anleitung  zur  Laryngoskopie,"  in  which  he  adopted  the 
principle  of  fixing  the  reflecting  mirror  to  a  stand  which  was  eventu- 
ally modified  into  the  present  so-called  Tobold's  apparatus.  The 
original  idea  of  this,  however,  is  to  be  found  in  Tiirck's  papers. 

A'oltolini'^  contributed  much,  by  the  originality  of  his  diction  and 
the  fertility  of  his  in^•entive  powers,  to  the  spread  and  advance  of 
the  art  in  Germany  especially  as  to  nasopharyngoscopy  and  the 
employment  of  the  galvanocautery.  Post-rhinoscopy  was  at  first 
eagerly  pursued  by  Voltolnii  and  Semeleder  as  an  aid  to  the  passage 
of  the  Eustachian  catheter. 

We  have  recited  the  attempt  of  Ephraim  Cutter  in  America  to 
utilize  prisms  in  laryngoscopy.  He  and  his  predecessor  in  England, 
Worden,  were  alike  unsuccessful  in  turning  to  account  the  principles 
of  refraction,  but  his  letters  published  by  Elsberg  are  significant 
of  how  well  extended  was  the  idea  of  the  practicability  of  laryn- 
goscopy at  the  time  Garcia  demonstrated  it. 

Strangenwald,^  Church,'^  Krackowitzer''  and  John  H  Douglas^ 
and  Horace  Green  in  1861  reported  the  new  art  in  America. 

Louis  Elsberg,  to  whose  exhaustive  work*  I  am  indebted  for 
much  of  my  information  as  to  early  laryngological  literature  in 
America,  in  1862^  and  186.')'°  published  papers  on  the  laryngoscope 
and  laryngoscopic  technique.  The  latter  more  than  anyone  else 
was  active  in  drawing  attention  in  America  to  the  value  of  the 
new  art,  and  for  some  time  previous  to  these  publications  he  had 

1  British  and  Foreign  Medico-Chirurgical  Review,  London,  Jan.,  1SG3,  XXXI, 
p.  209. 

-  Zur  Laryngoskopischcn  Tochnik,  St.  Petcr.sbin-g.  med.  Zeitsch.,  18G1, 1,  p.  22. 

^  Die  Laryngoskopie  und  Pharvngoskopie,  186L 

■*  American  Med.  Monthly  and  New  ^'ork  Review,  July.  ISBO,  Vol.  XIV,  p.  15. 

°  Bulletin  of  the  X.  Y.  Aoademv  of  Medicine,  ISGl,  Vol.  I,  p.  156. 

«  Ibid.,  p.  162.  "  "  Ibid. 

8  Trans.  Am.  Lar.  Ass'n,  1879,  Vol.  I,  3.3. 

'  Am.  Medical  Monthly,  N.  Y.,  1862,  Vol.  XVIII,  p.  385. 

10  Am.  Medical  Times,  N.  Y.,  May,  9,  1863,  VI,  p.  226;  Dec.  26,  1863,  VII, 
p.  297. 


212  THE  LARYNGOSCOPE 

taught  the  technique  in  the  University  Medical  College  in  New 
York  City.  His  attention  had  been  attracted  and  his  ardor  stimu- 
lated by  Czermak,  who  had  sent  him  his  book.  These  studies 
and  observations  he  brought,  in  1863,  before  the  New  York 
Academy  of  Medicine  and  the  American  Medical  Association. 
He  also  thus  early  urged  the  value  of  topical  applications  to  the 
larynx.  Horace  Green  lived  to  see  an  instrument  of  precision 
prove,  before  the  Academy  of  ^Medicine,  the  claims  which  he  had 
advanced  there  so  courageouslv  and  so  tenaciouslv  manv  vears 
before,  but  he  himself  took  no  acti^ie  part  in  developing  in  his 
native  country  the  art  of  laryngoscopy.    He  died  in  1800. 

It  was  several  years  after  Elsberg  became  active  in  the  propaga- 
tion of  laryngology  in  America  that  others  joined  him. 

In  1860  J.  Solis  Cohen,  of  Philadelphia,  began^  that  long  series 
of  communications  which  have  done  so  much  to  establish  the 
specialty  of  laryngology  in  America  and  to  stimulate  its  steady 
advance  for  nearh'  fortv  vears. 

Larsmgological  Clinics  and  Instruction. — In  the  ^Medical  Schools 
and  Universities  instruction  was  soon  given  in  the  art  of  Laryngo- 
scop3\  Tiirck  and  Semeleder  are  rect)rded  as  giving  instruction 
in  Vienna  in  1801,  the  former  being  created  professor  in  1804.  In 
other  large  cities,  as  welP  as  in  Vienna,  private  and  public  instruc- 
tion was  soon  to  be  easily  obtained  by  the  student.  In  1801  Elsberg 
had  begun  teaching  laryngoscopy  in  New  York,  and  in  1808  in  the 
catalogue  of  the  University  of  the  City  of  New  York,  ^Medical 
Department,  his  name  appears  as  Professor  of  Diseases  of  the 
Throat,  but  not  until  1875  was  laryngology  included  in  the 
curriculum  of  the  Harvard  ]\Iedical  School,  and  that  of  the  New 
York  College  of  Physicians  and  Surgeons.  After  this  it  soon 
became  a  department  of  nearly  all  the  teaching  medical  institu- 
tions. In  the  dispensaries  and  hospitals  of  New  York  City, 
special  clinics  were  formed  about  the  same  time.  The  throat 
department  of  the  New  York  Eye  and  Ear  Infirmary  was 
separated  from  the  Aural  Department  in  1873.  In  1875  a 
department  for  Diseases  of  the  Throat  was  opened  at  the  New 
^^^rk  Dispensary. 

Laryngological  Literature. — The  new  specialty  of  laryngology 
found  place  for  its  publications  at  first  exclusively  in  the  general 
medical  literature  of  the  day,  but  especially  in  the  otological 
journals,  "The  Archiv  fiir  Ohrcnheilkunde,"  founded  in  1804  in 
A'ienna,  and  especially  in  the  "  Monatsschrift  fiir  Ohrcnheilkunde," 
founded  by  Voltolini  in  ISOO,  in  Berlin.    The  "  Annales  des  Maladies 

1  Vid.  Med.  Record,  N.  Y.,  1866,  I,  p.  178  et  seq.;  Am.  Jour.  Med.  Sciences, 
April-Oct.,  1867,  n.  s.,  LIII,  p.  404. 

^  I  regret  very  much  that  more  exact  and  accurate  information  is  not  at  my 
disposal  of  the  beginnings  of  laryngological  instruction  in  various  capitals  of 
th;.'  civilized  world. 


LARYNGOLOGICAL  SOCIETIES  213 

de  I'oreille,  dii  larynx,  etc.,"  be^aii  its  issue  in  1874  in  France. 
"The  American  Archives  of  Laryngology"  began  its  short-Hved 
career  in  1880  (ten  years  later  began  the  first  issue  of  "The  Laryn- 
goscope"), the  "Archivii  Italiani,"  in  1881,  the  Spanish  "Revista 
de  Laryngologia,"  etc.,  in  1887,  while  the  English  "Journal  of 
Laryngology"  also  did  not  issue  its  first  number  until  1887. 
Li  1884  Semon  began  his  comprehensive  index  of  laryngological 
literature,  the  "Centralblatt  fiir  Laryngologie,"  while  it  was  not 
until  1893  Fraenkel  began  his  stately  Archiv,  which  has  done  so 
much  in  the  last  few  years  to  supply  us  with  the  best  thought  of 
the  workers  in  our  own  special  field. 

This  at  present,  of  course,  does  not  by  any  means  exhaust  the 
list.  In  fact  the  special  literature  dealing  with  the  nose  and  throat 
has  now  become  of  such  enormous  bulk  that  it  is  impossible  for 
any  one  man  to  peruse  anything  more  than  a  small  part  of  even 
the  most  important  books,  essays,  and  reviews. 

Text-books  as  we  have  seen  were  rapidly  issued  and  grew  quickly 
from  small  brochures,  their  first  editions,  to  the  respectable  volumes 
of  Tiirck,  Cohen,  Fauvel,  and  ^lackenzie.  Of  late  years  the  exhaus- 
tive composite  works,  of  which  Heymann's  Handbuch  is  the  most 
striking  example,  are  monuments  of  intellectual  acti\ity  and  rest- 
less endeavor.  Li  every  encyclopaedic  work  on  general  medicine 
or  surgery,  laryngology,  and  rhinology  occupy  a  relatively'  large 
number  of  pages.  Since  Friedreich's  casual  remark  our  knowledge 
of  the  diseases  of  the  upper  air  passages  has  increased  enormously, 
and  the  literature  of  the  subject  still  more  so. 

Laryngological  Societies. — America  claims  precedence  in  the 
formation  of  special  laryngological  societies.  The  Xew  York 
Laryngological  Society  began  its  sessions  in  1873,  which,  howe^■er, 
were  gradually  discontinued,  and  the  organization  of  a  throat 
section  in  the  Academy  of  Medicine  in  1885  practically  took  its 
place.  The  American  Laryngological  Association  held  its  first 
meeting  in  1879  under  the  presidency  of  Louis  Elsberg.  The 
Liternational  Medical  Congress  of  1881  established  a  section  for 
laryngology  and  rhinology.  Other  special  societies  were  formed 
throughout  the  world  somewhat  later.  Since  1 888  they  have  existed 
in  abundance,  but  still  have  a  tendency  to  multiply.  Thus  was  the 
art  of  laryngoscopy  and  the  science  of  laryngology  spread  through- 
out the  principal  countries  of  the  civilized  world. ^ 

We  may  now  take  notice  of  the  great  strides  immediately  taken 
in  the  knowledge  of  the  various  phenomena  of  disease  of  the  upper 
air  passages. 

'  For  afullor  list  of  special  journals  and  toxt-books  and  societies,  see  the  Index 
Catalogue  of  the  Library  of  the  I'nited  States  Surgeon-General's  office  under 
the  heading  of  Laryngology,  Rhinology,  etc.  The  lists  have  grown  to  such 
dimensions  that  it  is  quite  impracticable  to  inrlude  them  even  in  an  appendi.x 
to  this  work. 


214  IXTRALARYXGEAL  OPERATION 

Laryngeal  Tumors. — Xo  subject  so  immediately  engaged  attention 
as  that  of  laryngeal  tumors.  Forming  striking  pictures  in  the 
laryngeal  mirror,  causing  marked  and  distressing  symptoms, 
cajjahle  of  immediate  relief  by  means  of  instruments  under  the 
guidance  of  the  laryngoscope,  and  last,  but  by  no  means  least, 
afl'ording  the  operator  a  chance  to  display  in  the  most  brilliant 
manner  his  newly  acquired  skill,  the  larynges  of  the  civilized  world 
were  soon  swept  so  clear  of  benign  neoplastic  excrescences,  that 
one  is  today  almost  tempted  to  account  for  their  present  rarity 
by  supposing  the  early  laryngologists  even  removed  the  tendency 
to  their  formation.  And  yet  even  here  we  are  able  to  go  far  back 
in  the  history  of  medicine,  and  note  not  only  the  observations 
of  laryngeal  tumors  postmortem,  but  even  their  extraction  ycr 
vias  naturales. 

jNlarcellus  Donatus^  in  a  vague  wav  doubtless  referred  to  larvn- 
geal  growths  in  the  early  part  of  the  seventeenth  century  when  he 
spoke  of  warts  in  the  throat,  fauces,  and  root  of  the  tongue.  He 
says  they  are  rare,  but  occur  at  times.  Edward  Tyson,^  in  1627, 
wrote  of  having  diagnosticated  a  polypus  of  the  bronchi  and  trachea 
from  the  expectoration  of  fleshy  masses  by  a  young  man,  but  he 
was  not  able  to  obtain  an  autopsy  to  confirm  his  diagnosis,  and  it 
is  not  certain  he  did  not  observe  fibrinous  shreds. 

Ilaller^  refers  to  a  case  of  an  ulcerous  tumor  of  the  epiglottis 
and  "three  scirrhous  and  round  tubercles  seated  between  the  mem- 
branes" of  the  uterus.  The  epiglottic  tumor  was  of  such  a  size 
that  wonder  was  expressed  that  the  woman  had  not  died.  We  may 
suppose  it  was  an  epithelioma. 

Lieutaud  in  the  middle  of  the  eighteenth  century  recorded^ 
observations  of  two  cases  postmortem,  in  which  laryngeal  polypi 
has  caused  death. 

The  First  Intralaryngeal  Operation. — "A  laryngeal  polypus  which 
Levret  could  not  ligate  with  his  instrument,  G.  Koderik,  a  surgeon 
in  Brussels,  ligated  with  much  ease  by  means  of  an  instrument 
which  was  constructed  out  of  a  row  of  hollow  balls.  This  flexible 
instrument  may  ])erliai)S  be  very  useful  in  certain  cases  in  which 
the  stiff  catheter  renders  no  aid."'' 

John  C.  Cheeseman,  in  1817,  was  doubtless  the  first  in  America 
to  describe^  a  laryngeal  growth.     His  is  the  earliest  illustration  of 

1  De  Historia  Medica  Mirabili,  Lib.  Ill,  Cap.  V,  Francofurti  a.  M.,  1613,  p. 
24.3. 

^  Acta  Modica  Thoma'  Barlholini,  Hafni;i!,  1G8(),  Lib.  V,  p.  94. 

■'  Pathological  Observations,  London,  17.56,  Obs,  VIII,  p.  14. 

*  Historia  Anatomica  Medica,  Parisiis,  1767,  Vol.  II,  p.  297,  Obs.  63  and  64. 

^  This  is  as  explicit  a  refcronce  as  I  can  find  to  the  first  autlicnticated  case 
of  intralaryngeal  operation  for  a  neoplasm.  II(u-binaux's  r(>i)ort  in  tlu?  .Jour, 
fie  Med.,  Paris,  1770,  not  being  at  my  disposal,  I  have  it  from  Lewin's  Deutsche 
Klinik,  No.  13,  March  29,  1862,  XIV,  p.  121,  who  himself  quotes  it  from 
Ilichter's  Chirurgische  Bibliothek. 

^  Transactions  of  the  Physico-Medical  Society  of  New  York,  1817,  Vol.  I, 
p.  413.    Case  of  a  remarkable  disease  of  the  larynx  and  trachea,  with  a  plate. 


INTRALARYNGEAL  OPERATION  BY  AID  OF  LARYNGOSCOPY    215 

such  a  growth  with  which  I  am  famihar.  It  was  a  case  of  papil- 
k^ma  of  the  vocal  cords  dying  without  relief.  Albers  remarked/ 
in  LS34,  that  "tumors  in  the  cavity  of  the  larynx  belong  to  a  class 
remarkable  alike  for  their  rarity  and  their  characteristic  s^'uiptoms," 
and  in  1837  Trousseau  and  Belloc  could  only  report  from  literature 
and  their  own  experience  seven  cases. 

Cheeseman's  case  is  omitted  from  Ehrmann's  otherwise  appar- 
ently complete  list  of  the  obser^'ations  which  had  been  noted  up  to 
the  date  of  the  appearance  of  his  work  in  1S50,-  including  his  own 
two  cases,  31  in  all.  He  also  reported  two  cases  of  laryngeal  polypi 
in  horses  and  three  in  cows.  Ehrmann  said  something  of  the 
structure  of  laryngeal  polypi,  dividing  them  histologically  into 
fibrocellular  and  polypoid  excrescences,  these  latter  including  what 
we  call  i)apilloma. 

Shortly  after  P]hrmann's  paper  Horace  Green^  published  a  work 
on  the  subject.  He  there  speaks  of  having  removed,  by  means  of 
a  knife  and  a  bent  tenaculum,  a  laryngeal  polyp  from  a  child  of 
eleven,  which  he  could  see  by  forcible  depression  of  the  tongue. 
He  boldly  and  quickly  cut  the  tumor  at  its  base,  certainly  a  very 
skilful  operation  under  the  easily  imagined  circumstances.  It 
must  of  course  ha\'e  been  a  pedunculated  tumor,  springing  from 
the  upper  part  of  the  larynx  in  a  very  tractable  patient.  In  another 
case,  that  of  a  man,  he  used  a  sponge  probang  and  cauterized  the 
base  of  what  was  evidently  a  polyp.  Still  another  growth,  which  was 
probably  malignant,  was  partly  removed  by  knife  and  tenaculum. 

]Middeldorpf^  succeeded,  by  means  of  an  incandescent  platinum 
wire  looj),  in  removing  in  1853  a  polyp  which  he  supposed  sprang 
from  the  upper  part  of  the  larynx.  The  tongue  was  forcibly  pulled 
out  by  a  sharp  hook,  and  the  tumor  was  encircled  with  the  wire 
by  means  of  the  fingers.  He  at  this  time  was  able  to  cite  (54  cases 
of  laryngeal  polypi  before  his  own.  A  few  only  of  this  number 
had  obtained  relief  by  operative  interference,  yet  some  of  these 
as  we  have  seen,  were  extracted  yer  vias  naturales  before  the  days 
of  the  laryngoscope.  Nevertheless,  this  was  ver^-  exceptional, 
and  when  we  realize  that  Ehrmann  spoke  the  truth  in  saying, 
"Polypi  of  the  larynx,  left  to  nature,  become  sooner  or  later  the 
cause  of  sudden  death,"  we  are  able  to  appreciate  what  laryngoscopy 
did  for  these  sufferers. 

The  First  Intralaryngeal  Operation  by  the  Aid  of  Laryngoscopy. — 
Immediately  laryngological  literature  abounded  in  r(>i)orts  of  the 
diagnosis,  intra  vitam,  of  this  morbid  condition.  Lewin,  in  1801, 
declared''  that  he  had,  thus  far,  seen  fifty  to  sixty  cases  of  laryngeal 

'  Jour,  der  Chirurgie  uiiil  .VuffenluMlkunde,  Berlin,  ISol,  XXI,  llefl  -1,  p. 
517. 

2  C.  H.  Ehrmann:   Histou-e  des  Polypes  du  Larvnx,  ISoO. 

3  Polypi  of  the  Larynx.  N.  Y.,  1852. 

*  Die  Galvanocaustik,  Breslau,  1S54,  p.  222. 

*  Allgeineine  mcdicinische  Central-Zeilung,  Oct.  12,  1861,  XXX,  654. 


216  INTRALARYNGEAL  GROWTHS 

neoplasms,  and  that  they  were  present  in  5  or  0  per  cent,  of  all 
cases  of  laryntjeal  afl'ections.  He  had  operated  on  seven  of  these, 
three  by  cutting  operations  and  four  by  caustics.  Subsequently' 
in  an  exhaustive  paper  he  pictured  forceps  and  laryngeal  cautery 
electrodes.  He  there  states  he  operated  on  his  first  case  July  20, 
1860,  and  upon  his  second  case  in  November,  1861.  We  must, 
therefore,  conclude  so  far  at  least  as  certain  publications  indicate 
it,  that  Lewin  was  the  first  to  attempt  the  extirpation  of  a  laryn- 
geal growth  under  the  guidance  of  the  laryngoscope.  Von  Bruns' 
title  allotting  to  himself  the  credit  of  the  first  operation  therefore 
is  misleading,'  though  of  course  he  probably  knew  nothing  of  Lewin's 
publication.  It  nevertheless  gave  rise  to  considerable  controversy. 
After  long  traim'ng  of  his  brother's  throat,  he  succeeded  in  removing 
a  growth  from  his  larynx  by  means  of  a  forceps.  In  another  work^ 
in  1865  he  was  able  to  report  sixteen  cases  operated  on  in  various 
ways. 

In  1866,  Elsberg  published^  a  pamphlet  on  the  subject.  It  was 
a  work  of  considerable  merit,  with  some  very  good  plates  of  the 
microscopic  appearances  of  papilloma,  and  less  good  colored 
plates  of  laryngeal  growths  in  situ.  In  1867,  J.  Solis  Cohen 
reported"  the  intralaryngeal  removal  of  a  polyp. 

The  laryngeal  knife,  which  of  late  has  been  discarded  as  a  Aery 
dangerous  instrument,  was  the  favorite  weapon  of  these  early 
operators,''  who,  we  may  suspect,  did  not  always  report  their 
mishaps  with  it.  ^'on  Bruns,  however,  invented  a  number  of  other 
devices  for  his  work. 

So  rapidly  did  the  observations  of  these  growths  multiply,  that 
by  1871  one  man  was  able  to  report  from  his  own  experience  100 
cases.  In  this  year,  IMorell  Mackenzie  published  his  essay  on 
"Growths  in  the  Larynx,"  which  he  differentiated  into  papillomata, 
benign  epithelial  growths,  fibromata,  fibrocellular  or  mucous 
polypi,  myxomata,  spindle-celled  sarcomata,  cystic  tumors, 
adenomata,  and  angeiomata.  He  pictured  various  intralaryngeal 
instruments  of  his  own  invention,  among  them  his  laryngeal  forceps, 
and  the  devices  of  others.  His  obser\ati()ns  began  in  1S()2,  and 
in  eight  years  he  had  seen  100  cases  himself,  and  he  was  able  to 
collect  the  reports  of  189  cases  by  others,  published  since  the 
introduction  of  the  larvngoscope,  ascribing  the  first  case  to  Lewin, 
in  1860. 

1  Deutsche  KUnik,  No.  12,  1862,  XIV,  p.  Ill,  If. 

'  Die  Erste  Ausrottung  eines  Polypen  in  der  Kchlkopfhohle,  von  Victor  v. 
Bruns,  Tiibingen,  1862,  2  Aufl. 

^  Die  Laryngoskoiiic  und  die  Laryngoskopisrho  Chirurgie,  Tiibingen,   186.5. 

''  Laryngoscopal  (Surgery,  Illustrated  in  the  Treatment  of  Morbid  Growths 
within  the  Larynx,  being  the  prize  essay  to  which  the  American  Medical  Asso- 
ciation awarded  the  gold  medal  for  1865. 

5  Am.  Jour,  of  the  Medical  Sciences,  April,  1867,  LIII,  p.  404. 

^  Vid.  Ueber  Kehlkopfneubildungen,  von  Dr.  Otto  Prinz,  Archiv  der  Heil- 
kunde,  1866,  VII,  p.  193. 


TONSILS  217 

]\Iany  observers  treated  them  by  applications  of  caustics,  but 
this  method  soon  found  its  proper  fiekl  of  therapy.  It  is  interesting 
to  note  in  the  table  of  Fauvel/  that  he  had,  up  to  1S7G,  seen  300 
cases  of  laryngeal  neoplasms,  beginning  in  1862,  when  he  saw  eight, 
and  reaching  the  highest  figure  in  1873,  when  he  saw  40  cases. 
To  the  modern  observer,  even  in  our  largest  hospital  clinics,  these 
now  seem  fabulous  figures.  The  rapid  differentiation  of  these 
growths  is  to  be  noted  in  both  ^Mackenzie  and  Fauvel's  works. 
Lefferts-  was  able,  in  1876,  to  diagnosticate  and  operate  on  a  case 
of  eversion  of  the  laryngeal  ^•ent^icles,  cases  having  been  previously 
observed  by  Mackenzie  (1.  c.)  and  ]Moxon.^ 

Tonsils. — The  modern  history  of  the  development  of  our  knowl- 
edge of  the  tonsils  does  not  present  those  striking  advances  which 
are  evidenced  for  instance  in  that  of  accessory  sinus  disease,  or 
even  in  that  of  the  differentiation  of  atrophic  rhinitis.  Its  history 
may  be  epitomized  in  the  remark  that  such  progress  as  has  been 
made  has  been  along  lines  entirely  dependent  upon  the  advance 
of  general  medical  and  surgical  knowledge.  Yet  this  meagreness  of 
results  has  been  due  to  no  fault  ascribable  to  lack  of  studv  and 
analvsis.  In  no  other  domain  of  larvngologv  has  there  been  a  more 
prolific  literature.  Shortly  before  and  shortly  after  the  close  of 
the  nineteenth  century  the  amount  of  literature  dealing  with  the 
subject  of  tonsils  and  adenoids  became  enormous,  especially  in 
America.  America  indeed  at  that  time  was  producing  nearly  half 
of  the  laryngological  literature  of  the  world  and  nearly  three  times 
the  amount  of  anv  other  nation,  so  far  as  the  titles  of  abstracts 

t.  - 

indicate  it  for  the  year  1900  in  the  Centralblatt  fiir  Laryngologie. 
It  is  given  as  an  even  1000.  A  very  large  proportion  of  this  work 
was  devoted  to  the  subject  of  tonsils  and  adenoids^  and  of  it  a  not 
inconsiderable  number  of  papers  were  chiefly  concerned  with  the 
tonsils  as  a  port  of  entry  for  infection,  tuberculous  and  other. 
But  this  was  the  acme  of  activity,  in  spite  of  the  fact  that  the 
attention  of  otologists  had  been  more  directly  called  to  the  impor- 
tance of  nasopharyngeal  affections  in  the  etiology  of  ear  disease. 
Already  by  1902  the  number  of  references  to  be  found  to  tonsils 
and  adenoid  papers  had  fallen  off  so  that  the  largest  number  of 
reports  referred  to  in  any  one  number  was  scarcely  more  than 
20  and  the  total  number  in  the  year  was  less  than  a  quarter  of 
what  it  had  been  two  years  previously. 

We  have  seen  that  Schneider,  Santorini,  and  Ilaller,  under  a 
different  name,  had  fully  described  the  pharyngeal  tonsil.  The 
gross  anatomv  of  the  faucial  tonsils  had  been  known  and  studied 

1  Fauvel:  Traito  Praticiuo  dos  Maladies  du  Larvnx,  Paris,  1876. 

2  Lefferts:  Medical  Record,  lS7t),  \'()1.  XI,  p.  359. 

'  Aloxon:  Trans.  Path.  Soc,  London,  1868,  XIX,  p.  65. 
■•  For  instance  in  one  number  (2)  there  were  115  titles  of  papers,  not  counting 
diphtheria,  on  the  subject  of  tonsils  and  adenoids  out  of  a  total  of  221. 


2 IS  THE  PHARYNGEAL  TONSIL 

from  the  earliest  times  as  \ve  have  also  seen.  The  clinical  symptoms 
of  acutely  inflamed  tonsils  and  of  chronic  enlartrement  of  the 
faucial  tonsils  had  lonji:  been  known.  Methods  for  their  remo\al 
had  long  been  practised  before  the  days  of  the  laryngoscope.  iMany 
of  the  instruments  used  in  the  operation  have  been  })erfected. 
The  use  of  the  microscope,  making  possible  the  more  minute  study 
of  the  embryology  and  histology  of  the  tonsils,  made  strides  in  the 
middle  of  the  nineteenth  century  of  such  im])()rtance  that  the  results 
were  soon  striking  in  all  fields  of  medical  activity.  In  lSo9  Rapp^ 
made  a  study  of  the  comparative  anatomy  of  the  tonsils.  He 
made  no  mention  of  their  miiuite  structure.  We  may  infer  that 
at  the  time  of  the  discover^'  of  the  cell  bv  Schleiden  and  Schwann 
it  was  practically  unknown,  at  least  in  its  modern  sense.  But 
soon  after  this  the  impetus  their  discovery  had  upon  medical 
science  is  seen  in  the  history  of  laryngology.  Still  the  actual 
appreciati(m  that  the  histology  of  the  tonsils  as  of  other  of  the 
tissues  is  a  necessitj'  in  the  study  of  their  function  and  of  their 
disease  was  of  slow  growth.  The  presence  of  the  lymphoid  tissue 
in  the  nasopharynx  was  long  well  known  to  anatomists  before 
]\Ieyer  in  1868  drew  attention  to  its  importance  as  a  pathological 
phenomenon. 

The  Pharyngeal  Bursa. — F.  J.  C.  Mayer-  in  1842  described  the 
tissue  of  the  ])harynx  as  constituting  a  bursa  and  Tortual'*  referred 
to  it  as  the  superior  sinus  of  the  fauces.  While  Kolliker'*  in  1852 
had  a  fairly  good  knowledge  of  some  of  the  finer  anatomical  features 
of  the  faucial  and  lingual  tonsils  and  compared  them  to  the  Peyer's 
patches  in  the  intestines,  he  gives  no  very  satisfactory  description 
of  the  like  tissue  in  the  nasopharynx,  beyond  recognizing  it  as 
exactl}^  similar  in  finer  structure  to  the  tissue  in  the  oropharynx, 
lienle^  in  his  classical  work  in  1SG()  referred  indefinitely  to  depres- 
sions and  blind  dilatations  to  be  found  in  the  mucous  membrane 
of  the  nasopharynx.  He  admitted  the  existence  of  Mayer's 
"bursa  ])liaryngea"  as  a  normal  structure. 

The  Pharyngeal  Tonsil. — Luschka*"'  fully  described  the  median  and 
lateral  recesses  of  the  pharyngeal  tonsil,  declaring  he  had  always 
found  it  when  he  looked  for  it.  His  book  on  the  subject  is  a  master- 
piece among  the  brochures  of  anatomy.  He  also  was  well  acquainted 
with  many  of  its  embryological  features.  He  declared  there  was 
an  embryonic  connection  between  it  and  the  hypophysis.    Against 

1  Rapp:  Miiller's  Archiv  fiir  Anatomic,  Physiologic,  etc.,  Jahrg.,  1839,  p.  180. 

-  F.  J.  C.  Mayer:  Ncue  Untersuciiungen  aus  dem  Gebiete  der  Anatomic  und 
Physiologic,  Bonn,  1842. 

^  Tortual:  Ncue  Untersuchungcn  iiber  den  Bau  des  menschhchen  Schlundes 
und  Kclilkopfcs,  Leipzig,  1846. 

'  K<')llii<er:  Mikroskopi.sche  Anatomic,  Leipzig,  1852,  II,  2,  1,  p.  41. 

^  Henlc:  Handbuch  der  systematischen  Anatomic  des  Mensehen,  1866,  Band 
II,  p.  83. 

"  Luschka:  Der  Schlundkopf  des  Mensehen,  1868. 


WILHELM  MEYER  219 

this  idea  in  the  following  year  Dursy^  protested  in  a  work  on  the 
compa^ati^•e  embryology  of  the  head  and  its  structures. 

Tornwaldt's  Disease. — The  conception  of  the  earlier  anatomists 
of  the  regular  existence  of  a  normal  pharyngeal  bursa  led  Tornwaldt- 
in  1885  to  speak  of  an  affection  of  this  cavity  as  the  usual  origin 
and  cause  of  postnasal  catarrh.  It  was  spoken  of  and  is  still 
known  as  "Tornwaldt's  Disease." 

While  it  is  possible  that  the  cases  observed  by  Loewenberg^  and 
more  probably  the  cases  observed  by  Voltolini^  were  really  adenoids, 
this  does  not  detract  in  the  slightest  from  the  originality  of  Wilhelm 
Meyer's  great  clinical  discovery.  Wagner^  in  1865  had  described 
the  anatomical  structure  of  what  he  called  "  Pharyngeal  Granula- 
tions." 

Wilhelm  Meyer. — Wilhelm  ]Meyer  had  reported  his  observations 
on  this  lymphoid  hypertrophy,  in  Copenhagen,  in  1868,  and  later 
published  in  London''  his  paper  "On  Adenoid  ^'egetation  in  the 
Nasopharyngeal  Cavity."  It  is  difficult  to  find,  in  the  annals  of 
medicine,  a  first  report  of  a  morl:)id  process  which  so  thoroughly  in 
one  essay  exhausts  the  subject  from  almost  every  point  of  view.  So 
common  that,  after  his  attention  had  been  drawn  to  the  condition, 
he  was  able  to  detect  it  in  102  cases  in  eighteen  months,  with  symp- 
toms so  characteristic  that  the  veriest  tvro  in  medicine  now  easilv 
suspects  their  presence  at  a  glance,  with  certainty  of  relief  so  quickly 
afforded  by  a  simple  surgical  procedure,  it  certainly  seems  marvelous 
that  the  condition  should  have  been  so  long  undetected.  The  prac- 
tice of  postrhinoscopy  had  failed  to  reveal  it.  Notwithstanding 
that  Czermak  and  his  followers  for  ten  years  had  been  accustomed 
to  explore  by  vision  the  cavity  of  the  upper  pharynx,  it  was  left 
to  an  observer  comparatively  unfamiliar  with  postrhinoscopy  to 
detect  it  with  his  finger.  In  seeking  for  the  cause  of  a  Eustachian 
catarrh  in  a  patient,  he  pushed  his  finger  above  the  velum  palati 
and  thus  became  aware  of  a  morbid  growth,  the  removal  of  which 
has  alleviated  as  much  suffering  and  prevented  as  much  disable- 
ment as  any  surgical  procedure  ever  devised  by  the  wit  of  man. 
Not  only  by  his  thorough  expose  of  the  whole  subject  did  Wilhelm 
]\Ieyer  thus  confer  an  inestinial)le  boon  on  suflering  humanity, 
but  he  has  furnished  a  subsequent  generation  of  rhinologists  with 
their  most  lucrative  source  of  income.  No  other  event  since  the 
discovery  of  the  laryngoscope  has  so  contributed  at  once  to  the 
glory  and  profit  of  the  specialty  of  laryngology.  With  much  more 
reason  then  than  Tagliacozzi's  contemporaries  and  followers  gazed 

'  Dursy:  Zur  Kiitwickelungsgescliichte  des  Kopfes  des  Menschen  uml  der 
h()hereii  \\'irbelthiere,  Ti'ibingpn,  1SG9. 

-  Tornwaldt:  Ueber  die  Bcdcutung  der  Bursa  Pharj^ngea,  Wiesbaden,  1S85. 
^  Loewenberg:  Archiv  flir  Ohrenheilkundc,  18()5,  (1867)  Vol.  II,  p.  110. 
*  Voltolini:  Die  An\ven<lung  dor  Cialvanokaustik,  etc.,  Wien,  1SG7,  p.  66. 
^  Wagner;  Archiv  der  Heilkunde,  1865,  \l,  p.  'MS. 
"  Meyer:  Medico-Chirurgioal  Transactions,  INTO,  Vol.  53  (n.  s.,  35),  p.  191. 


220  HISTOLOGY  OF  THE  PHARYNX 

upon  his  statue  in  Bologna,  may  the  modern  rhinologist,  and 
liis  i:)aticnt  ahke,  ^vitll  unstinted  reverence,  view  the  figure  of 
Wilhehn  ^Meyer,  as  it  stands,  erected  by  them  in  1898,  in  the  "  (Jefion 
Platz"  in  Copenhagen.  While  only  five  cases  had  been  previously 
noted,  and  while  \Yal(leyer  and  his  followers  have  subsequently 
further  elucidated  the  histology  of  lymi)h()id  hypertrophy,  notliing 
of  vital  importance  remains  to  be  said  of  the  history  of  "Adenoids" 
after  Wilhehn  Meyer. 

The  Embryology  and  Histology  of  the  Pharynx. — Schwabach^  in 
18SS  also  protested  against  the  idea  of  Luschka  that  the  bursa 
pharyngea  had  embryonic  affinities  with  the  hypophysis  and 
contributed  valuable  papers  to  the  literature  of  the  development 
of  the  pharyngeal  tonsil.  G.  Killian,'-  in  1888,  in  a  masterly  essay 
on  the  sul)ject  of  the  comparative  embryology  of  the  i)haryngcal 
tonsil,  disagreed  with  the  view  of  Schwabach  and  regarded  the 
pharyngeal  bursa  as  an  atavistic  structure  in  the  walls  of  which 
develop  lymph  follicles  without  the  formation  of  crypts  and  that 
thus  the  development  and  structure  is  not  analogous  to  that  of  the 
faucial  tonsil.  Mayer,  Luschka,  Tornwaldt,  Schwabach,  and  Killian 
believed  in  the  bursa  as  an  embryonic  formation.  Ganghofner 
did  not.  Schwabach  seems  to  have  confused  the  pathological 
cavity  with  the  physiological. 

Schmidt,'^  in  1863,  had  studied  the  embryonic  development  of  the 
tonsils  in  mammals.  He  there  broached  a  point  in  the  embryogeny 
of  the  tissues  which  still  remains  a  question  among  histologists 
and  embryologists.  He  drew  attention  to  the  intimate  relationship 
of  the  epithelium  and  of  the  lymphoid  tissue  in  the  structure  of 
the  tonsils.  Ganghofner,*  in  1878,  gave  a  full  review  of  the  literature 
on  the  structure  and  development  of  the  j)haryngeal  tonsil  and 
bursa,  regarding  the  latter  as  a  normal  structure  in  the  child, 
resulting  from  the  firmer  adhesion  of  the  bottom  of  the  middle 
recess  with  the  underlying  aponeurosis,  a  true  recess  representing 
a  more  or  less  deep  depression  of  the  mucosa  of  the  pharynx. 

Leukocyte  Emigration. — Stohr^  as  early  as  1882  noted  the  profuse 
emigration  of  lymphoid  cells  through  the  epithelial  layers  of  the 
tonsil  at  all  ages,  and  asserted  it  was  a  physiological  and  not  a 
pathological  state.  He  also  observed  that  the  line  between  epithe- 
lium and  connective  tissue  is  frequently  obliterated.  He  seems 
to  have  been  the  first  to  note  the  wanderings  of  the  leukocytes 
through  the  epithelium.  Stohr  and  Ketterer  about  1884  began  a 
series  of  papers  which  greatly  elucidated  the  structure  and  added 

'Schwabach:  Archiv  fiir  mikroskop.  Anatomie,  1887,  XXIX,  p.  61,  and 
1888,  XXXII,  p.  187. 

2  O.  Killian:  Morphologischos  Jahrhurh,  1888,  XIV,  p.  018. 

^Schmidt:  Zeitschrift  fur  wissenschaftliche  Zoologic,  1863,  XIII,  p.  221. 

^  Ganghofner:  Sitzungsbcricht  dcr  K.  K.  Akadeniie  der  Wissenschaften, 
Wien,  1878,  Band,  78,  p.  182. 

'-  Stohr:  Biologisches  Ccntralblatt,  1882,  Band  II,  No.  12,  p.  309. 


EPITHELIAL  ORIGIN  221 

to  our  knowledge  of  the  embryogenesis  of  the  tissues  of  the  lymphoid 
structures.  Stohr/  recognizing  the  mingling  of  the  leukocytes 
with  the  epithelial  layers  of  the  lymphoid  tissue,  was  of  the  opinion 
that  they  are  originally  derived  in  embryonic  life  from  the  blood 
stream  and  reach  the  situation  of  the  lymph  nodes,  there  proliferate, 
and  thence  emigrate  through  the  epithelial  layers  to  the  surface 
forming  the  corpuscular  elements  of  the  buccal  and  pharyngeal 
secretions. 

Epithelial  Origin. — Retterer,-  on  the  other  hand,  believed  these 
tonsillar  elements  are  derived  from  the  epithelium  of  the  ectoderm 
and  entoderm  and  not  from  the  mesoderm.  The  lymphoid  cells 
are  given  off  from  the  basal  layers  of  the  epithelium  which  are 
invaginated  in  the  course  of  forming  the  crypts,  while  from  the 
mesoderm  comes  the  fibrous  frame-work  of  the  tonsils. 

Cordes,^  Wood,*  and  Wright,^  many  years  later,  came  to  accept 
the  view  expressed  at  this  time  by  Retterer  at  least  insofar  as 
pathological  conditions  are  concerned.  Their  experience  in  the 
histological  examination  of  tonsils  convinced  them  that  the  basal 
layers  of  the  epithelium  in  hypertrophied  tonsils  give  rise  to  the 
lymphocytes,  Wood  also  accepting  this  view  for  their  embryonic 
origin.  Hammar,*^  in  1903,  ga^•e  a  very  good  resume  of  the 
literature  and  a  classical  account  of  the  embryology  of  the 
pharynx,  and  asserted  that  the  embryonic  origin  of  the  lymphoid 
cells  is  neither  from  the  blood,  as  Stohr  asserted,  nor  from 
the  epithelium,  as  still  elaborately  maintained  by  Retterer,  but 
from  the  fixed  connective-tissue  cells.  Retterer  in  later  papers 
asserts  that  the  connective  tissue  is  also  derived  from  the  basal 
layers  of  the  epithelium.  Both  Stohr  and  Retterer  also  noted  the 
tendency  of  the  lymph  cells  to  gather  around  the  epithelium  of  the 
ducts  of  the  racemose  glands,  and  Stohr  especially  speaks  of  it  in 
connection  with  his  remarks  on  the  histology  of  the  lingual  tonsil. 
Swain,'  in  1886,  also  gave  an  early  and  very  good  description  of 
the  anatomical  and  clinical  features  of  the  lingual  tonsil.  Bickel* 
gave  a  very  extensiNC  literary  review  of  the  snbject  of  the  tonsils,  of 
the  fauces,  tongue,  and  pharynx  in  1884,  beginning  with  Vesalius. 
He  also  gave  an  excellent  anatomical  account  of  the  examina- 
tion of  a  large  number  of  postmortem  specimens.      Trautmann,' 

1  Stohr:  Virchow's  Archiv,  1884,  XCVII,  p.  211. 

*  Retterer:  Jouriuil  de  ranatomie  et  de  la  i)hysiologic,  1888,  XXIV,  p(i.  I 
and  274.  Ibid.,  November-December,  1908,  XLIV,  p.  470,  and  May-June,  1901), 
XLV,  p.  225.    Semaine  Mcdicale,  January  27,  ISSti,  VI,  p.  32. 

'  Cordes:  Ai-chiv  fiir  Laryngologie  und  Rhinologie,  XII,  1901,  p.  203. 

*  Wood:  University  of  Pennsylvania  Medical  Bulletin,  October,  1904,  XVII, 
p.  246. 

»  Wright :  The  Laryngoscope,  July,  1909,  XIX,  p.  488. 

*  Hammar:  Archiv  fiir  mikroskop.  Anatomic,  1903,  LXI,  p.  404. 

'  Swain:  Deutsches  Archiv  fiir  khnische  Medizin,  1886,  XXXIX,  p.  504. 
8  Bickel:  Virchow's  Archiv,  1884,  XCVII,  p.  340. 

'  Trautmann:  Anatomische,  pathologischc  und  klinische  Studien  iiber 
Hyperjilasie  dcr  Rachentonsille,  etc.,  Berlin,  1886. 


222  HISTOLOGY  OF   THE  TONSIL 

Bresgen,'  Toniwaldt,-  Schwabach^  in  Germany  and  ^Nlorgan^  in 
this  country,  discussed  the  question  of  the  existence  of  the  ])liaryn- 
geal  bursa  in  man  and  the  distribution  of  the  lymplioid  material 
in  the  pharynx.  ^Nleyer^  himself  took  part  in  it  in  a  lengthy  review 
of  Trautmann's  brochure.  Schaefi'er'"  and  others  refused  to  accept 
Tornwaldt's  idea,  but  from  this  time  on  Tornwaldt's  disease  has 
become  an  accepted  term  in  rhinology.  ]Many  reports  of  cysts 
formed  by  the  agglutination  of  the  median  and  lateral  folds  were 
made  for  a  time  after  Tornwaldt's  paper.  It  was  the  source  of  much 
fruitful  investigation.  Poelchen"  ])ublished  some  observations 
on  the  anatomy  of  the  nasopharynx  which  went  to  uphold  Torn- 
waldt's contention  of  the  existence  of  the  pharyngeal  bursa  as  an 
anatomical  structure,  but  there  was  no  frank  acknowledgment  of 
it  as  being  more  than  a  depression  in  the  mucosa  emphasized 
often  by  the  hyperplasia  of  the  median  folds.  Gerber*  and  Ziem^ 
discussed  the  question  of  Tornwaldt's  disease  in  1S90.  Chiari^** 
regarded  the  pharyngeal  bursa  as  an  agglutinative  inflammation 
of  the  walls  of  the  median  recess  of  the  pharyngeal  tonsil,  which  is 
a  little  more  frequently  met  with  than  the  like  phenomena  of  the 
lateral  recesses,  neither  being  very  common.  Allen^^  contributed 
a  valuable  paper  to  the  literature  of  the  morphology  and  pathology 
of  the  tonsil  in  1891.  Wright,^^  jj^  1895,  described  cyst  formations 
in  the  faucial  and  pharyngeal  tonsils  as  due  not  only  to  the  agglu- 
tination of  surface  folds  or  of  the  mouths  of  crypts  but  to  degen- 
eration of  the  parenchyma  of  the  tonsil. 

In  the  last  twenty  years  a  number  of  papers  have  been  written 
of  importance  dealing  largely  with  the  anatomy  of  the  tonsil. 
J.  Killian,!^  Finder,"  Goodale,'^  and  Levinstein^''  wrote  papers  in 
which,  while  the  anatomy  and  physiology  of  the  tonsil  was  dis- 
cussed, they  also  contributed  matter  of  value  to  the  literature  of 
the  embryogeny,  pathology,  and  clinical  aspects  of  the  subject. 
Wright,'^  in  1906,  demonstrated  the  occurrence  of  fat  in  the  lym- 
phoid tissue  of  the  tonsils,  and  showed  experimentally  that  at  least 

^  Bresgen:  Deutsche  medizinische  Wochenschrift,  Xo.  5,  1887,  XIII,  p.  86. 

2  Tornwaldt:  Ibid.,  No.  23,  p.  501. 

3  Schwabach:  Ibid.,  No.  26,  p.  578. 

*  Morgan:  Maryland  Medical  .Journal,  March  5,  1887,  XVI,  p.  3.53. 

^  Mever:  Internat.  Ccntralblatt  fiir  Laryngologic  und  Rhinologie,  1886-7, 
Jahr.,  Ill,  p.  60. 

6  Schaeffer:  Monatsschrift  fiir  Ohronhoilkunde,  No.  8,  1888,  XXII,  p.  207. 

'  Poelchen:  Virchow's  Archiv,  1890,  Band  119,  j).  118. 

8  Gerber:  Therapoulische  Monatsschrift,  1S90,  IV,  p.  24. 

»Ziem:  Ibid.,  1890,  IV,  p.  187,  also  Virchow's  Archiv,  1890,  Band  119,  p. 
569. 
'"  Chiari:  Wiener  klinische  Wochenschrift,  No.  4,  1891. 
"  Allen:  Transactions  American  Laryngological  Assoc,  1891,  p.  12. 
^^  Wright:  New  York  Medical  Journal,  December  7,  1895,  LXII,  p.  705. 
'^  J.  KiUian:  Archiv  fiir  Laryngologic  und  Rhinologie,  1898,  VII,  p.  167. 
'••  Finder:  Ibid.,  1898,  VIII.'p.  3.54.  '^  Goodale:  Ibid.,  1902,  XII,  p.  399. 

i«  Levinstein:  Ibid.,  XXII,  1909,  p.  209. 
1'  Weight:  New  York  Medical  Journal,  December  15,  1906,  Vol.  84,  p.  1161. 


PHYSIOLOGY  OF  THE  TONSIL  223 

some  of  it  may  be  derived  from  the  passing  food,  but  it  seemed 
probable  that  some  of  it  is  due  to  the  change  of  the  protein  in  the 
cell  bodies  of  the  lym])hocytes,  but  some  also  may  be  due  to  the 
affinity  of  such  cells,  when  their  cytoplasm  undergoes  degenerative 
change,  for  fat  in  the  general  circulation. 

Accessory  Tonsil. — Jurasz,^  Morgan,^  and  Bandler^  reported 
cases  of  the  so-called  accessory  or  supernumerary  tonsil  in  1885 
and  1889.  Since  then  a  number  of  reports  of  such  cases  have  been 
made,  including  also  reports  of  papillomata  of  the  tonsil.  j\Iany 
such  reports,  it  seems  probable,  referred  to  exceptional  instances 
of  the  retrograde  metamorphosis  of  the  tonsils.  An  auxiliary 
method  of  tonsillar  regression  was  declared  by  AYright^  to  be  a 
process  whereby  small  pieces  of  the  tonsils  are  automatically  severed 
from  the  general  mass  by  fibrosis  and  absorption  of  the  strands 
of  tissue  connecting  them,  a  process  which  he  called  autoclasis  of 
the  tonsil. 

Physiology  of  the  Tonsil. — We  must  now^  return  to  such  an  account 
of  the  ideas  in  regard  to  tonsillar  functions  as  have  been  discussed 
in  the  last  thirty  years  which  it  is  possible  to  glean  from  the  work 
to  some  of  which  I  have  already  devoted  a  few  pages.  In  the  first 
volume  of  Semon's  Centralblatt  (p.  10)  issued  in  1884,  reference 
is  made  to  expressions  of  opinion  that  are  still  true  enough  and 
are  still  made  by  the  student  of  general  medicine.  Writers  declared 
then  and  they  declare  now  that  the  tonsils  are  part  of  the  general 
lymphatic  system.  They  missed  then  and  they  miss  now  the  salient 
point  which  laryngologists  have  come  to  appreciate — the  tonsils, 
pharyngeal  and  faucial — are  indeed  enlarged  lymph  glands,  but 
unlike  lymph  glands  elsewhere  they  are  exposed  to  an  external 
environment  of  infection  which  introduces  at  once  a  unique  problem, 
— How  does  this  particular  lymph  gland  respond  to  its  unique 
environment?  It  is  the  attempt  to  answer  this  which  furnished 
the  chief  interest  in  the  subject  for  a  generation  to  laryngologists, 
handicapped  as  they  have  been  by  a  deficiency  in  their  training 
for  the  task  of  answering  it,  and  handicapped  by  a  deficiency  of 
perception  of  the  problem  by  those  capable  of  aiding  them. 

At  that  time,  as  there  has  been  before  and  since,  a  notion  pre- 
vailed among  the  laity  and  among  general  practitioners  to  some 
extent  that  the  tonsils  had  some  connection  with  the  sexual  organs 
and  with  voice  production;  with  the  former  question  Semon^  busied 
himself  in  1885  and  Gould''  in  188G.  Needless  to  say  the  former 
condemned  the  idea  and  it  has  been  generally  discredited  in  scientific 
circles.    With  such  ideas  I  do  not  propose  to  encumber  these  pages. 

1  Jurasz:  Monatsschrift  fiir  Ohrenheilkunde,  1885,  XIX,  p.  361  et  seq. 

^  Morgan:  Transactions  American  Laryngological  Ass'n,  1889,  p.  4. 

'  Handler:  Prager  niedizinische  Wochenschrift,  No.  43,  1890,  XV,  p.  535. 

*  Wright:  The  Laryngoscope,  April  1904,  XIV,  p.  257. 

5  Semon:  St.  Thomas'  Hospital  Reports,  1885,  Vol.  XIII,  p.  125. 

«  Gould:  British  Medical  Journal,  October  16,  1886,  II,  ]).  720. 


224  LEUKOCYTE  EMIGRATION 

Stohr'  in  the  beginning::  of  his  research  suspected  tliat  the  meaning 
of  the  emigration  of  the  leukocytes  from  the  tonsil  was  that  they 
take  up  the  degenerated  material  of  the  parenchyma  of  the  tonsil 
and  carr\'  it  out  of  the  bodv,  but  he  does  not  venture  to  state  that 
this  is  a  functional  act  or  that  the  material  they  carry  out  is  dele- 
terious. Kingston  Fox  developed  practically  the  same  idea^  in 
1886,  based  no  doubt  on  the  observations  of  Stohr.  IlilP  practically 
embodied  this  in  a  report  to  the  Otological  Section  of  the  British 
Medical  Association  in  1888.  Briicke/  in  1854,  had  stated  that 
both  the  faucial  and  the  intestinal  follicles  add  to  the  number  of 
leukocytes  in  the  lymph  which  passes  through  them.  This  was 
confirmed  thirty  years  later  by  the  more  elal)()rate  investigations 
of  Flemming,^  Drews,^  and  Paulsen''  in  1885.  They  showed  that 
the  leukocytes  were  manufactured  by  lymphocytes  at  the  germinal 
centres  of  the  lymph  nodes.  Briicke  had  looked  upon  such  collec- 
tions of  lymphoid  material  in  the  fauces  and  the  intestines  as 
absorbing  organs.  The  demonstration  by  Stohr  of  a  current  of 
leukocytes  going  out  of  the  tonsil  seemed  to  contradict  this  assump- 
tion of  Briicke,  and  in  1891  Hodenpyl'*  in  a  work  incidental  to  a 
valuable  disquisition  on  the  finer  anatomy  of  the  tonsil  came  to 
the  conclusion  from  various  experimental  and  histological  observa- 
tions that  they  have  no  absorptive  power.  He  explained  their 
infection  with  the  germ  of  diphtheria  by  supposing  that  the  latter 
grew  on  surfaces  deprived  of  the  epithelium.  The  clinical  e\'idence, 
aided  by  the  enthusiasm  of  a  rising  school  of  high  contagionists 
in  bacteriology,  did  much  to  prevent  tlie  acceptation  of  these 
views.  In  1897  Goodale^  published  his  important  observation  on 
the  absorptive  power  of  the  tonsils  for  inorganic  matter.  Carmine 
granules  introduced  in  the  crypts  were  seen  apparently  passing 
through  the  epithelial  covering  into  the  lymphoid  tissue  beneath. 
This  gave  an  objective  support  to  previous  clinical  and  pathological 
observations.  This  work  was  repeated  and  confirmed  by  that  of 
Hendelsohn^'^  in  1898.  On  the  other  hand,  Brieger^^  repeated  the 
experiments  of  Goodale  and  Ilendclsohn  with  negative  results, 
urging  also  that  he  had  never  found  foreign  matter  under  the 
epithelium  of  those  who  are  exposed  continually  to  dust.  While 
Wright  later  obtained  positive  results,  there  are,  as  a  matter  of 
fact,  a  number  of  points  about  the  technique  of  the  demonstration 

'  Stohr:  Correspondenzblatt  fiir  Schweizer  Aerzte,  No.  17,  September  1, 
1890,  XX,  Jahrg.,  p.  537. 

2  Hingston  Fox:  Journal  of  Anatomy  and  Physiology,  July,  1886,  XX,  p.  559. 

3  Hill:  British  Medical  .Journal,  September  1,  1888,  II,  p.  487. 

*  Briicke:  Denkschrift  der  Wiener  Akademie,  1854. 

*  Flemming:  Archiv  fiir  niikroskop.  Anatomic,  1885,  XXIV,  p.  5.3. 

«  Drews:  Ibid.,  p.  338.  ^  Paulsen:  Ibid.,  p.  345. 

*  Hodenpyl:  International  Journal  of  the  Medical  Sciences,  March,  ISO  I. 
^  Goodale:  Archiv  fiir  Laryngologie  und  Khinologie,  1897,  VII,  p.  90. 

'"  Hendelsohn:    Archiv  fiir  Laryngologie  imd  Rhinologie,  1898,  VIII,  p.  476. 
"  Brieger:  Archiv  fiir  Laryngologie  und  Rhinologie,  1901,  XII,  p.  2.54. 


PHYSIOLOGY  OF  THE  TONSIL  225 

of  these  observers  that  need  the  control  of  otliers.  Xotwithstanding 
Brieger's  hesitation  in  accepting  the  experimental  results  of  Goodale 
and  Hendelsohn,  he  was,  neverthless,  disposed  to  believe  that  the 
pharyngeal  and  faucial  tonsils  offer  some  protection  against  the 
infective  diseases  of  childhood  and  adolescence.  Just  the  nature 
of  this  protection  he  did  not  venture  to  define  and,  singular  to  say, 
he  concluded  that  tonsillar  hypertrophy  is  a  part  of  a  constitutional 
dyscrasia,  hereditable,  whereby  enlargement  of  all  the  lymph 
glands  is  an  expression  of  scrofula  due  to  systemic  tuberculosis  or 
hereditary  syphilis.  Gorke^  wrote  a  number  of  important  articles 
on  the  physiology  and  pathology  of  the  lymphoid  tissue  in  the 
throat  in  1907  and  the  previous  years,  pointing  out  the  processes 
bv  which  it  retrogresses  after  childhood  and  the  reasons  which 
he  believed  suffice  to  consider  them,  when  not  unduly  enlarged,  a 
protection  rather  than  a  menace  to  the  organism,  meaning  thereby 
when  they  do  not  act  as  an  obstruction  to  respiration  and  to  the 
function  of  the  Eustachian  tube  and  to  the  drainage  of  the  pharynx. 
Opposed  to  this  was  the  idea  that  the  sunken  tonsil  is  often  danger- 
ous because  of  the  structural  changes  which  it  has  undergone. 
Between  the  idea  that  the  tonsil  should  be  removed  because  it 
was  too  large,  and  the  belief  that  it  is  a  source  of  danger  when 
small,  the  operating  laryngologist  has  reaped  a  golden  harvest. 
Gorke  surmised  that  the  circulating  lymph  of  the  tonsil  has  some 
special  bacteriolytic  effect.  This  subject,  together  with  that  of 
the  operative  procedures  on  the  tonsils,  was  reviewed  by  Hicguet 
and  others'-  in  1910.  Schoenemann'^  attempted,  in  1907,  to  answer 
the  question  as  to  whether  the  tonsils  and  adenoids  are  harmful 
or  protective  to  the  organism.  He  regarded  the  Stohr-Brieger 
theory  of  the  export  of  harmful  products  as  very  improbable, 
regarding  it  as  an  irrele\ant  activity  accessory  to  lymphoid  metab- 
olism. He  believed  the  chief  function  of  the  tonsils  is  to  be  sought 
in  the  internal  cell  activity  of  the  adenoid  tissue.  This  hypothesis 
seems  su]:)ported  by  no  evidence,  and  scarcely  any  argument,  by 
those  who,  like  Schoenemann,  have  alluded  to  it.  Levinstein^ 
declared  no  theory  of  the  function  of  the  tonsil  could  be  considered 
safe  from  criticism,  and  there  is  no  satisfactory  evidence  that  they 
perform  any  important  part  in  the  physiology  of  the  organism, 
but  he  did  not  deny  that  there  are  indications  to  the  contrary. 
Indeed,  it  still  remains  one  of  those  man>-  attractive  subjects  that 
make  medicine  a  delight  to  the  student  of  biological  science. 

1  Gorke:  .Axchiv  fiir  LarjTigologie  und  Rhinologie,  1904,  X^'I,  p.  14-1,  1907, 
XIX,  p.  244. 

^  Congress  of  the  Belgian  Otorhinolaryngological  Society.  Ref.  Semon's 
Int.  Centralblatt  fiir  Laryngologie  und  Rhinologie,  XXV'II,  1911,  p.  92.  See 
also  Broeckaert:  Archives  Internationales  de  Larvngologie,  Xos.  2  and  3,  1910, 
Tome  XXX,  p.  406,  819. 

^  Schoenemann:  ^Ionatsschrift  fiir  Ohrenheilkunde,  etc.,  1907,  XLI,  p.  179. 

*  Levinstein:  Archiv  fiir  Laryngologie  und  Rhinologie,  1910,  XXIII,  p.  75. 

15 


226  TONSILLAR  BACTERIOLOGY 

As  the  result  of  his  ()l)servati()ii  and  exj)eriinents  and  those  of 
others  in  the  question  of  tonsihar  absorption,  Wrij^ht,  in  1905, 
starting  from  a  stand-point  of  funclamental  ])liysico-ehemic'aI  prin- 
ciples, reasoning  that  there  must  be  an  equihbrium'  between 
infection  and  innnunity  in  the  tonsihar  (Ty])ts  which  accounts 
for  the  constant  presence  of  l)acteria  witiiin  them  and  their  only 
occasional  absor})tion  by  the  cryptal  walls,  drew  attention  to  the 
difference  in  the  behavoir  of  dust  from  that  of  })acteria-  in  ]!)()(). 
Poulain,''  Hammerschlag,^  and  Stheemann'^  having  shown  the 
relation  of  fat  to  some  of  the  activities  of  the  lymph  glands,  Wright,*^ 
in  1911,  in  a  series  of  papers  attempted  to  show  that  the  question 
of  absorption  or  repulsion  of  l)acteria  and  of  inert  matter  at  the 
surface  of  the  tonsils  is  dependent  upon  lij)oprotei(l  phases  of  sur- 
face tension  of  the  epithelial  cells  and  upon  the  fat  and  lipoid 
constituents  of  the  tonsillar  parenchyma.  These  varying  from 
time  to  time  furnish  the  mechanism  whereby  germs  and  dust  are 
excluded  or  admitted.  lie  claimed  that  while  it  is  improper  to 
speak  of  tonsillar  function,  the  study  of  these  biochemical  phe- 
nomena would  tend  to  explain  much  that  is  now  unknown  in 
the  mechanism  of  tonsillar  immunity  and  infection. 

Bacteriology  and  Bacterial  Infection  of  Tonsils.^ — The  organisms 
first  noted  in  the  tonsils  naturally  !)elonge(l  to  the  moulds  which 
are  associated  with  tonsillar  keratosis,  but  this  was  rather  due  to 
the  fact  that  they  were  erroneously  supposed  to  form  the  masses 
which  give  to  that  affection  its  striking  naked-eye  appearance. 
B.  FraenkeP  ga\e  the  name  of  mycosis  pharyngis  to  it  in  1873. 
The  predominant  organism,  called  at  one  time  Bacillus  fasciculatus 
by  E.  I'Vaenkcl,  was  later  identified  as  the  Leptothrix  buccalis. 
Heryng^  described  the  disease  in  1885.  As  long  ago  as  in  1885  and 
1886  a  large  number  of  English  authors  published  contributions 
in  the  British  ^Medical  Journal  and  The  Lancet  to  the  subject 
of  the  relation  of  tonsillar  inflanmiation  to  rheumatism,  a  question 
in  which  the  interest  has  of  late  years  been  revived.  The  British 
Medical  Association  had  api)oiiite(l  a  committee  to  investigate 
the  matter  and  it  had  rei)orted  that  there  is  no  etiological  rela- 
tionship between  the  two,  as  a  result  of  statistics  ^^  Inch  they  had 
collected.  This  is  a  subject  so  largely  involved  with  the  general 
history   of  medicine,   it  is  still   so  actively  discussed   in   coiitt^m- 

'  Wright :  Medical  News,  March  4,  1905,  LXXXVI,  p.  385. 

2  Wright:  New  York  Medical  Journal,  January  0,  inOCi,  Vol.  S3,  p.  17. 

'  Poulain:  J'^tudc  de  la  graisse  dans  le  ganglion  Ivmiihaticiue  normal  et 
patholog.,  These  de  Paris,  G.  Steinheil,  Ed.,  1902. 

*  Hammerschlag:  Virchow's  Archiv,  190S,  CXCIV,  p.  320. 

'  Stheemann:  Beitrage  zur  pathologischen  Anatomie,  etc.,  1910,  XLVIII, 
p.  170. 

«  Wright:  New  York  Medical  Journal,  February  11,  et  seq.,  1911,  XCIII, 
p.  257. 

'  B.  Fraenkel:  Berliner  klinischc  Wochenschrift,  1873,  X,  p.  94. 

8  Hcryng:  Zeitschrift  fiir  klinische  Medizin,  1885,  VII,  Heft  4,  p.  358. 


DIPHTHERIA  227 

poraneous  literature,  it  is  still  in  such  an  unsettled  state  that  I 
shall  not  attempt  to  do  further  than  direct  the  reader  to  the  series 
of  papers  in  the  two  English  journals  above  mentioned. 

Diphtheria.— So  markedly  are  the  symptomatic  and  prognostic 
features  of  that  most  frequent  form  of  croupous  inflammation  of 
the  mucosae  associated  with  the  presence  of  the  bacillus,  that  all 
other  forms  are  excluded  from  the  term  Diphtheria,  which  we  have 
seen  Bretonneau  applying  to  the  whole  category.  Looking  back 
to  the  treatise  of  Bretonneau,  we  again  see,  as  everywhere  and 
always  in  medicine,  that  the  progress  has  been  one  of  advance  m 
differentiation.  We  need  not,  therefore,  review  the  abundant 
literature,  which  appeared  in  the  long  interval  of  nearly  sixty 
years,  which  intervened  between  the  work  of  Bretonneau  and  the 
discovery  of  the  Klebs-Loeffler  bacillus.  Loeffler,i  in  1S84,  de- 
scribed more  fully  and  identified  more  clearly  the  bacillus  of  diph- 
theria previously  observed  by  Klebs.  Roux  and  Yersin,'-  in  1SS8, 
still  further  extended  our  knowledge  of  the  bacterium  usually 
found  in  croupous  inflammations,  so  that  it  became  possible  as  it 
had  previously  been  with  tuberculosis  to  classify  the  disease  from 
the  stand-point  of  the  bacteriologist  rather  than  from  that  of  the 
pathologist.  But  before  this  we  find  frequent  traces  of  the  belief 
in  the  germ  origin  of  the  disease.  Thus  Shurly  in  America  in  1879^ 
stated  his  belief  in  the  microbian  origin  of  diphtheria.  Koux  and 
Yersin  began  their  studies  on  diphtheria  in  1888  (1.  c),  and  con- 
tinuing them  for  several  years,  they  investigated  the  nature  of  the 
bacillus  and  its  toxins,  and  laid  the  foundation  for  the  production 
of  the  immunizing  serum  by  Behring,^  E.  Fraenkel,^  and  Roux  and 
^Martin.'' 

About  this  time  attention  was  again  drawn  to  that  class  of 
infectious  disease  of  the  tissues  around  the  upper  air  tube  of  which 
Hippocrates  had  so  much  to  say  and  of  which  Ludwig  wrote  (1.  c). 
Senator,  in  1888,  gave  a  very  careful  description'  of  phlegmon  of 
the  peripharyngeal  tissues,  and  numerous  papers  on  the  subject 
have  subsequently  appeared. 

In  1894,  after  the  i)ublication  of  the  \rdpev  of  Roux  and  Yersin, 
began  the  discussion  of  the  merits  of  antitoxin  in  diphtheria.  The 
serum  of  Behring  came  into  active  use,  and  in  the  Centralblatt 

1  Lonffler:  VerofTcntlichunson  dcs  Kuis.    C.osundhcitsamtos,  1884. 

2  Roux  and  Yersin:  Annales  de  I'lnstitut  Pasteur,  1888,  11,  p.  G29;  1889,  III, 

p.  273;  1890,  IV,  p.  385.  .     ,      .,  ,  ,  .-n 

3  Shurly:  Transactions  Detroit  Medical  and  Library  Ass  n,  February,  18/9, 

■>  Behring:    D(>utsche    luedizinische  Wochcnschrift,  Nos.  49-50,   1890,  XVI, 

p.  1113,  1145;  1893,  XVll  If.  ....,.tt 

*  E.  Fraenkel:    Berliner  klinische  Wochcnschrift,  No.  49,  1890,  XXMl,  p. 

1133 

6  Roux  and  Martin:  Annales  do  I'lnstitut  Pasteur,  No.  9,  1894,  VIIL  p.  009. 

"Senator:  Ucbcr  Akute  Infektiose  Plilegmon  des  Pliarynx,  \'erhaniUungen 
der  Berhner  medizinische  Gesellschaft,  1888,  Band,  XIX,  Ph.  2,  p.  10. 


228  TONSILLAR  BACTERIOLOGY 

fiir  Laryngolojiic  iiiul  Rhinoloijit',  Jalirg.  II,  p.  586  et  seq.,  may  be 
found  references  to  numerous  reports  on  its  practical  use.^ 

Intubation. — If  l)acteriolooy  wTouijlit  (jreat  chanties  in  the  nosolotry 
of  diphtheria,  intul)ati()n,  as  introthiced  by  O'Dwyer,  brought 
about  no  less  a  re\()lution  in  the  operati\e  treatment.  I  nknown 
to  him,  the  idea,  as  we  have  seen,  had  existed  in  the  very  earliest 
records  of  medicine.  It  is  a  matter  of  conjecture  how  far  Hippoc- 
rates introduced  his  tubes  into  the  air-way,  but  that  he  passed 
these  beyond  the  fauces  is  perfectly  ai)])arent.  All  through  the 
history  of  medicine,  especially  before  the  Renaissance,  and  after  the 
eighteenth  century,  the  references  are  numerous  to  this  Ilippocratic 
manoeuver,  but  how  often  it  was  practised  is  a  matter  of  doubt, 
probably  very  infrequently.  The  first  clear  account  of  its  use  is 
in  Bichat's  description-  of  the  operation  as  performed  by  Desault. 
He  passed  hollow  sounds  into  the  larynx,  and  gave  temporary 
relief  to  a  dyspnoeic  patient,  as  did  also  a  distinguished  surgeon  of 
Toulouse,  following  his  example.  This  was  near  the  end  of  the 
eighteenth  century.  Bichat  gi^•es  careful  directions  as  to  the  tech- 
nique. They  were  to  be  passed  through  the  nose.  While  Desault 
and  perhaps  others  were  occasionally  successful  in  affording  relief 
by  operations  performed  in  this  manner,  the  operation  could  not 
rival  that  of  tracheotomy.  The  same  criticism  may  be  applied 
to  the  revival  of  the  practice  by  Loiseau  in  1840^  and  by  Bouchut, 
who,  in  1858,  urged  its  use  in  the  laryngeal  stenosis  of  diphtheria.'* 
The  chief  honor  which  Bouchut  seems  to  ha\e  acquired  was  to 
draw  the  fire  of  his  famous  countryman,  Trousseau,  who  has 
brought  tracheotomy  into  greater  vogue  for  the  condition.  Trous- 
seau's predilection  for  the  operation  of  tracheotomy,  which  he 
practised  with  great  frequency,  no  doubt  had  something  to  do 
with  his  unfa\()rable  rei)ort  on  Bouchut's  claims,  but  this  predilec- 
tion could  not  have  arisen  from  the  contemplation  of  his  own  results 
in  diphtheria.  They  were  atrocious.  While,  therefore,  the  ide.i 
had  existed  from  hoary  antiquity,  and  while  during  the  preceding 
hundred  years  attempts  were  made  from  time  to  time  to  make  it 
more  practicable,  there  can  be  no  c|uestion  that  success  was  first 
attained  by  Joseph  O'Dwyer,  who  published  first  in  1885  the 
account^  of  his  long,  patient,  and  persistent  endeavors.  The  success 
which  attended  them  is  fresh  in  the  minds  of  us  all.  The  remarkable 
results  attained  of  late  years  by  the  administration  of  antitoxin 

1  See  especially  Britisli  Medical  Journal,  1  )(!LTnibcr  22-29,  1S9-4;  Bulletin 
Medical,  December  9,  1894,  VIII,  p.  10()7;  Berliner  klinische  Woehenschrift,  No. 
36,  1894,  XXI,  p.  827;  Deutsche  ined.  Woch.,  No.  \^^,  16,  17,  18,  19,  20,  32, 1894. 

-  CEuvres  Chirurgicales  de  Desault,  Edit,  by  Bichat,  Paris,  1798-9. 

^  Referred  by  him  to  this  date  in  a  communication  published  in  Gaz.  des 
Ilopitaux,  18.58,  p.  491. 

*  Bull,  de  I'Academie  Imp6riale  de  M6decine,  November,  1858,  XXIII,  p. 
1160;  I'Union  Medicale,  1858,  No.  130,  XII,  p.  517. 

6  O'Dwver:  New  York  Medical  Journal,  August  8,  1885,  XLII,  p.  145. 


FOLLICULAR   TONSILLITIS  229 

in  laryngeal  diphtheria  has  very  greatly  diminished  the  number  of 
cases  in  which  relief  from  dyspnoea  in  laryngeal  diphtheria  is 
imperatively   demanded. 

Follicular  Tonsillitis. — Owing  to  the  facilities  for  differential 
diagnosis  aft'orded  by  the  identification  of  the  Klebs-Loeffler 
bacillus,  croupous  tonsillitis  became  more  easily  distinguished 
from  diphtheria,  but  in  Holt's  paper^  it  may  be  seen  that  this 
was  appreciated  from  clinical  observation  before  the  bacterial 
new  knowledge  was  disseminated.  .Something  of  the  state  of 
knowledge  of  the  subject  and  of  the  relation  of  tonsillitis  to  rheuma- 
tism, scarlet  fever,  and  diphtheria  at  this  time  may  be  seen  in  a 
paper  of  B.  Fraenkel-  and  Fox.^  Cases  have  occasionally  been 
reported^  in  which  diphtheria  followed  operations  on  tonsils  and 
adenoids,  but  these  have  been  so  rarely  noted  that  the  fears 
expressed  of  such  an  event  in  former  years  have  not  been  realized.  In 
1895  Sendziak'^  contributed  to  laryngological  literature  in  Germany 
an  account  of  some  original  work  which  helped  to  establish  the 
fact  that  follicular  tonsillitis  in  spite  of  the  presence  of  the  pseudo- 
diphtheria  bacillus  is  not  identical  with  true  pharyngeal  diphtheria. 
The  same  may  be  said  of  the  communications  of  A'eillon'"'  and  of 
Jaccoud^  in  France  and  of  Wolfenden^  in  England.  Park^  published 
a  paper  on  the  bacteria  present  in  the  normal  throat  and  on  their 
relation  to  acute  throat  inflammations.  He  demonstrated  strep- 
tococci in  healthy  throats  which  seemed  harmless,  and  he  noted 
the  change  in  number  and  in  virulence  during  inflammations  and 
during  changes  of  the  weather.  Buschke,^"  in  an  extensive  article 
in  1894,  published  his  belief  that  the  tonsils  are  portals  of  infection 
for  the  bacterial  agents  of  sepsis. 

Numerous  articles,  after  this,  ascribed  various  organic  affections — 
pleurisy,  endocarditis,  nephritis,  rheumatism — to  tonsillar  infec- 
tion, while  in  addition  to  the  pyogenic  cocci  and  the  Klebs-Loeffler 
bacillus  other  organisms  were  found  associated  with  tonsillar 
inflammation.^^    Suchannek^'-  published  some  valuable  observations 

1  Holt:  New  York  Medical  Journal,  May  8,  1886,  XLIII,  p.  517. 

2  B.  Fraenkel:  Berliner  klinische  Wochenschrift,  No.  17  and  18,  1886,  XXIII, 
p.  265,  287. 

3  Fox:  The  Lancet,  July  31,  1886,  II,  p.  200. 

*  Caille:  New  York  Medical  Journal,  August  4,  1894,  LX,  p.  150;  Medical 
Record,  June  2,  1894,  XLV,  p.  704. 

^  Sendziak:  Ai-chiv  fiir  Laryngologie  und  Rhinologie,  1895,  Band  II,  Heft  2, 
p.  180. 

«  Veillon:  Archiv  de  Medecine  experiment.,  1894,  VI,  p.  161. 
'  Jaccoud:  1' Union  Medicale,  July  5,  1894,  LVIII,  p.  13. 

*  Wolfenden:  New  York  Medical  Journal,  September  15,  1894,  LX,  p.  348. 
s  Park:  Medical  Record,  January  27,  1894,  XLV,  p.  117. 

1°  Buschke:  Deutsche  Zeitschrift  fiir  C'hirurgie,  1894,  Band  38,  4-5  Heft,  p.  441. 

"  Lermoyez,  Helme,  and  Barbier:  A  Case  of  Chronic  Tonsillar  Inflammation 
Due  to  the  Bacterium  Coli  Communis;  Bulletin  Societe  M6dicale  dcs  hopitaux 
de  Paris,  June  22-28,  1894,  3  S6r.,  XI,  p.  449. 

1*  Suchannek:  Bresgen's  Sammlung  z\\angloser  Abhandlungen,  u.  s.  w..  Heft 
1,  1895. 


230  TONSILLAR   BACTERIOLOGY 

on  the  histology  of  py?emic  infection  of  the  tonsils  with  a  bibliog- 
raphy bearing  on  the  relation  the  jiroeess  has  to  Narious  systemic 
aii'ections  (rheumatism)  and  to  the  involvement  of  distant  organs. 
B.  Fraenkel  and  E.  Meyer,'  in  1S96,  contributed  articles  to  the 
literature  of  the  bacteriology  of  lacunar  tonsillitis.  Park-  drew 
attention  to  the  frecjuency  with  which  diphtheria  bacilli  are  found 
in  healthy  throats. 

From  these  and  innumeral)lc  other  works  dealing  directly  or 
incidentally  with  the  subject  it  has  long  since  been  known  that 
large  numbers  and  a  number  of  varieties  of  germs,  sometimes 
pathogenic,  live  as  saprophytes  in  the  crypts  of  the  faucial  and 
pharyngeal  tonsil,  in  persons  enjoying  a  fair  degree  of  good  health, 
both  local  and  systemic. 

Vincent's  Angina. — N'incent,''  in  J89S,  demonstrated  fusiform  bacilli 
and  spirilla  in  a  clinically  distinct  form  of  angina,  as  he  believed, 
and  it  has  since  been  known  under  his  name,  though  Plaut^  in 
(iermany,  in  1905,  engaged  in  a  controversy  with  him  as  to  priority. 
Many  others''  quickly  reported  cases.  In  many  pa])ers  on  the 
incidence  of  the  \'incent  l)acilli  in  membranous  tonsillitis,  attention 
was  called''  to  the  fact  that  the  identification  of  them  as  the  etio- 
logical factor  is  a  matter  of  some  doubt,  inasmuch  as  they  are 
frequently  found  in  fairly  normal  throats  and  associated  in  throat 
lesions  with  other  ))ath()genic  bacteria. 

Tuberculosis  of  the  Tonsil. — The  question  of  the  relationship  of 
tuberculosis  to  the  tonsils  has  taken  a  rather  more  complicated 
course.  After  MUemin  had  demonstrated  its  communicability, 
but  before  Koch  had  demonstrated  the  bacillus,  Cohnheim,'  in 
1878,  raised  the  c{uestion  if  tuberculous  glands  in  the  neck  were 
not  due  to  some  primary  afiection  of  the  buccal  and  pharyngeal 
mucosa  and  of  the  tonsils.  Tuberculosis  of  the  nose  and  of  the 
ear  had  been  reported.  Ortli,**in  1879,  in  some  feeding  experiments 
found  not  only  that  there  was  produced  in  guinea-pigs  cervical 
tuberculous  adenitis,  l)ut  in  one  case  tuberculous  tonsils.  In  1884 
Haumgarten'-'  confirmed  this.  Cornil  and  Uanvier,  in  the  1884 
edition   of  the  manual   of   pathological    histology,  described  the 

'  B.  Fraenkel  and  E.  Mej-er:  Archiv  fiir  Laiyngologie  unci  Rhinologie,  1896, 
Band  IV,  pp.  130  and  249. 

2  Park:  Medical  News,  May  12,  1900,  LXXVI,  p.  759. 

'  Vincent:  Archives  Internationales  de  laryngologie,  etc.,  1898,  XI,  p.  44. 

^  Plant:  Mi'inchener  niedizinisclio  Wochensclirift,  No.  27,  1905;  Vincent: 
Prcsse  Mddicale,  March  29,  1905.  XIII,  p.  193. 

'  Craig:  Medical  News,  March  10,  1900,  LXXVI,  p.  374.  Letulle:  Bull, 
et  M(5m.  Soci6t6  Medicale  des  hopitaux,  December  14,  1900,  3  iSer.,  XVII,  p. 
1197.     Conrad:  Arcliiv  fiir  Laryngologie  und  Rhin..  1903,  XIV,  p.  525. 

'  For  instance:  Bliihdorn;  Deutsche  medizinische  Woch.,  No.  25,  1911, 
XXXVII,  p.  1154. 

'  Cohnheim:  Die  Tuberculose  vom  Staiidpuukl  dcr  Infektionslehre,  1881. 

*Orth:  Lehrbuch  der  8pcciellen  jiatliologische  Anatomic,  Band  I,  p.  663. 
Virchow's  Archiv,  1879,  Band  76,  p.  217. 

"  Baumgarten:  Centralblatt  fiir  klinische  Medizin,  No.  2,  1884,  V,  p.  25. 


TUBERCULOSIS  OF  THE   TONSIL  231 

lesion  of  tonsillar  tuberculosis  and  Strassmann^  in  that  year  spoke 
of  its  frequency  in  phthisical  patients.  He  found  it  13  times  in  21 
such  patients.  This  seems  to  have  been  the  beginning  of  the  special 
literature  of  the  subject,  as  it  drew  attention  to  its  latency  in  the 
tonsil  in  cases  of  tuberculosis.  Abraham,'-  in  1885,  wrote  on  tonsillar 
tuberculosis  in  English.  In  1891  Dmochowski^  came  to  the  con- 
clusion that  tuberculous  deposits  in  the  tonsils,  both  faucial  and 
lingual,  are  due  to  auto-infection.  Couvreur/  in  1892,  quoted  a 
number  of  reports  in  which  it  seemed  probable  that  a  tuberculous 
tonsil  was  the  starting-point  of  a  descending  tuberculous  cervical 
adenitis.  Schlenker*^  published  investigations  on  tuberculosis  in 
man  which  included  observations  on  the  tonsils  and  the  cervical 
lymph  glands,  and  drew  the  conclusions  more  or  less  supported  by 
recent  work  that  the  tonsils  are  infected  sometimes  primarily  by 
the  bacilli  in  the  f(wd — more  often  by  the  bacilli  in  the  sputum 
from  the  lungs.  He  gave  careful  account  of  postmortem  observa- 
tion in  24  cases  and  a  full  bibliography  of  this  early  stage  of  the 
question.  Lermoyez  ,'^  in  1894,  referred  to  two  cases  in  which  general- 
ized tuberculosis  followed  the  operation  for  the  removal  of  adenoids. 
Another  report  of  a  case  was  made  by  Wright''  in  1896.  Kriickmann,^ 
as  a  result  of  postmortem  examination  in  64  cases,  confirmed  the 
observations  of  Strassmann,  Dmochowski  and  Schlenker. 

Naturally  all  this  work  resulted  in  fixing  upon  the  tonsils,  as 
the  source  of  infection  in  cervical  adenitis,  the  attention  of  laryn- 
gologists  and  later  of  the  general  practitioner,  and  they  were 
receptive  to  the  demonstrations  which  followed.  After  the  report 
of  Dieulafoy,  experiment  and  observation  in  the  question  became 
much  more  frequent.  The  paper  of  Dieulafoy,^  in  1895,  excited 
great  interest.  He  showed  that  tuberculosis  of  the  tonsil  often 
existed  without  cervical  symptoms  and  called  it  larval  tuberculosis. 
Out  of  sixty-one  cases  of  the  hypertrophy  of  the  lingual,  faucial, 
and  pharyngeal  tonsils,  in  eight  cases,  or  about  twelve  per  cent., 
he  detected  tubercle  by  animal  inoculation.  Whether  all  the 
results  were  due  to  the  tubercle  bacillus  in  the  tonsil,  or  in  its 
crypts,  was  a  question.    It  was  shown  by  Cornil  that  if  the  bacilli 

1  Strassmann:  Virchow's  Archiv,  1884,  XCVI,  p.  319. 

2  Abraham :  Tubercle  of  the  Tonsil,  Dublin  Journal  of  Medical  Science, 
October,  1885,  LXXX,  p.  346. 

'  Dmochowski:  Beitrage  zur  pathologischen  Anatomie,  etc.,  1891,  X,  p.  481. 

*  Couvreur:  De  I'adenopathie  cervicale  tuberculeuse  consideree  surtout  dans 
ses  rapports  avec  la  tuberculose  pulmonaire,  Paris,  1892. 

5  Schlenker:  Virchow's  Archiv,  1893,  134,  p.  145. 

^  Lermoyez:  Bull,  et  Mem.  de  la  Societe  Medicale  des  hopitaux,  July  20, 
1894,  Ser.  3,  XI,  p.  559;  Annales  des  Maladies  de  I'oreille,  etc.,  No.  10,  October, 
1894,  XX,  p.  979. 

'  Wright:  New  York  Medical  Journal,  September  26,  1896,  LXIV,  p.  412. 

*  Kriickmann:  Virchow's  Archiv,  1894,  Band  138,  p.  534. 

9  Dieulafoy:  Bull,  de  I'Academie  de  Mcdecine,  April  31,  May  7-14,  1895, 
S6r.  3,  XXXIII,  p.  437  et  seq.;  Archives  Internat.  do  Larvngologie  ct  Rhinolo- 
gie,  July-August,  1895,  VIII,  p.  191. 


232  TUBERCULOSIS  OF  THE   TONSIL 

were  in  the  stroma  they  had  not  produced  recognizable  histological 
lesion.  Others  who  attem])ted  to  confirm  Diculafoy's  results  by 
his  technique  were  ranch  embarrassed  l)y  the  animals  used  (guinea- 
pigs),  succumbing  to  infection  by  others  of  the  cryptal  flora,  but 
subsequent  histological  investigations  have  shown  the  essential 
accuracy  of  Dieulafoy's  results,  though  on  the  whole  the  percentage 
of  larval  tuberculosis  in  all  unselected  cases  of  hypertrophied  ton- 
sils has  been  shown  to  be  hardly  more  than  a  half  that  percentage 
in  the  average  of  the  reports,  a  very  large  number  having  now 
appeared.'  It  is  impossible  further  to  extend  the  reference  to  this 
important  subject  beyond  the  few  years  following  Dieulafoy's 
paper.  Ten  years  later  it  had  entered  on  a  new  phase.  Latent 
tuberculosis  in  general  was  found  to  be  almost  universal  in  adult 
life,  and  the  percentage  very  high  in  children,  if  we  are  to  reckon 
the  number  of  people  harboring  the  tul)ercle  bacillus.  The  advent 
of  the  technique  of  skin  reactions,  the  use  of  antiformin  in  experi- 
mental and  microscopic  work,  have  confirmed  the  conclusions  of  the 
statistics  of  postmortem  examinations,  furnished  many  years  ago 
by  Xaegeli — that  we  are  all,  in  adult  life,  a  little  tuberculous. 
Sobernheim  and  Blitz,-  by  means  of  the  von  Pirquet  reaction, 
found  that  large  numbers  of  children  with  adenoids  and  tonsils 
react,  indicating  a  latent  tuberculosis,  but  the  adenoids  removed 
produced  no  animal  tuberculosis  when  injected  after  treatment 
by  the  antiformin  method.  The  children  who  before  had  shown 
a  positive  von  Pirquet  reaction  showed  a  positive  reaction  after 
the  removal  of  the  adenoids.  There  is  a  good  bibliographical 
reference  in  their  article.  Beitzke,'^  in  1906,  had  drawn  attention 
to  the  fact  that  the  cervical  lymphatics,  in  children  at  least,  do 
not  communicate  with  the  thoracic,  so  that  bevond  the  level  of 
the  larynx  there  can  be  no  descending  or  ascending  infection 
between  the  tonsils  and  the  lungs,  and  that  pulmonary  tuberculosis, 
so  far  as  tonsillar  infection  in  children  is  concerned,  must  be  a 
blood-born  disease,  the  lymphatics  from  the  pharynx  being  drained 
direct  into  the  vena  cava.  In  1912  he  further  showed,  as  did 
Joest^  and  others,  that  markedly  increased  positive  evidence  of  the 

1  G.  Gottstein:  Berl.  klinische  Wochcnschr.,  No.  31,  1896,  XXXIII,  p.  689. 
Brindel:  Revue  H6bd.  de  LaryngoL,  etc.,  No.  30-31,  1896,  XVI,  881,  913. 
Ruge:  Virchow's  Archiv,  1896,  Band  144,  p.  431.  Goruc:  Annales  dcs  Maladies 
de  I'Oreille,  etc.,  No.  5,  1897,  XXIII,  p.  437.  Walsham:  British  Med.  Journal, 
May  7,  1898,  I,  p.  1199.  McBride  and  Turner:  Edinburgh  Med.  Journal,  April, 
May,  and  June,  1897,  n.  s.,  I,  pp.  35.5,  471,  .WS.  Friedmann:  Zieglcr's  Bcitriige 
zur  j)atholog.  Anat.,  etc.,  1900,  XXVI II,  p.  66.  Labbe  and  Levi-Sirugue : 
Gazette  des  Ilopitaux,  February  17,  1900,  LXXIII,  p.  193.  Lartigau  and 
Nicoll:  Amer.  Jour.  Med.  Sci.,  June,  1902,  CXXIII,  p.  1031. 

2  Sobernheim  and  Blitz:  Archiv  f.  Laryngologie  u.  Rhinologie.,  1911,  Band 
25,  p.  121. 

3  Beitzke:  Virchow's  Archiv,  1906,  Band  184,  p.  1. 

■•  Beitzke-Joest,  etc.:  Verhandlungen  der  deutschen  pathologischen  Gesell- 
schaft,  1912. 


OPERATIONS  FOR   TONSILS  AND  ADENOIDS  233 

existence  of  latent  tubercle  in  the  general  lymph  glands  could  be 
shown  by  histological  examination  and  experimental  obsenation. 

The  question  recently  raised^  in  bacteriological  literature  as  to 
the  identity  of  the  bacillus  of  tubercle  producing  tonsillar  and 
glandular  tuberculosis  in  children  promises  to  prove  of  vital  interest 
to  the  student  of  tonsillar  tuberculosis. 

Tonsillar  Syphilis. — There  is  little  of  special  laryngological  interest 
from  a  historical  point  of  view  in  the  literature  of  syphilis  of  the 
nose  and  throat.  A  very  large  number  of  reports  may  be  men- 
tioned^ of  the  primary  lesion  noted  more  often  on  the  tonsils  and 
lips  than  elsewhere  in  its  extragenital  incidence.  Bulkley,^  in  1S93, 
reported  a  large  number  of  cases,  15  chancres  of  the  lip,  20  chancres 
of  the  tonsil  out  of  a  total  of  110  cases  altogether  of  extragenital 
chancres  noted  in  his  own  practice.  Numerous  such  reports  have 
appeared  in  literature  since  then. 

Operations  for  Tonsils  and  Adenoids. — Practically  at  every  epoch 
in  the  history  of  medicine  the  removal  of  the  tonsils  has  met  with 
opposition  even  by  medical  men — no  more  in  antiquity  than  in 
the  era  immediately  following  the  paper  of  Meyer.  Evulsion  of 
the  tonsils  continued  a  practice  with  many  operators  after  the 
invention  of  the  modern  forms  of  tonsillotomes  and  has  been  revived 
of  late  years  in  the  attempts  now^  in  vogue  at  a  more  complete 
removal  of  lymphoid  tissue  from  the  throat.  The  question  of  how 
to  operate  has  been  very  carefully  studied,  and  doubtless  there 
has  been  considerable  improvement,  if  we  are  to  accept  the  view^ 
that  it  is  desirable  to  remove  as  much  of  the  lymphoid  hypertrophy 
as  possible  from  the  vault  of  the  pharynx  and  from  the  oropharynx. 
The  question  when  to  operate  has  unfortunately  been  very  inade- 
quately discussed.  This  defect  in  the  scientific  study  of  the  problem 
has  been  largely  due  to  the  incomplete  appreciation  of  the  fact 
that  the  existence  of  a  considerable  amount  of  tissue  in  the  naso- 
and  oropharynx  is  a  normal  condition  and  entirely  compatible 
with  good  health.  At  the  International  Congress  in  1884  Bosworth 
insisted  that  the  faucial  tonsils  do  not  exist  as  anatomical  entities 
in  the  normal  throat.  Semon  and  Fraenkel  denied  this  and  they 
further  deprecated  the  recommendation  of  Bosworth  that  e\'ery 
tonsil   should   be   extirpated.     Bosworth^   repeated   this  doctrine 

1  Park  and  Kjumwiede:  Journal  of  Medical  Research,  Oct.,  1910,  XXIII, 
No.  2,  p.  205. 

2  Spillman:  Rev.  med.  de  I'Est,  1878,  X,  292.  Hulot:  Ann.  de  derm,  and 
syph.,  1878-9,  X,  p.  29.  Schiragew:  St.  Petersburg,  medizinische  Wochenschrift, 
No.  39,  1880,  V,  p.  323.  Hamonic:  Annales  de  Dermatologie  et  de  Syph.,  1882, 
2  Ser.,  Ill,  p.  393.  Von  Boeck:  Ref. :  Monatshefte  f.  praktische  Dei-matologie, 
October,  1883,  II,  p.  317.  Morel-Lavallee:  Annales  de  Dermatologie  et  de 
Syph.,  July-August,  1883,  2  Ser.,  IV,  p.  39.  Hue:  La  France  Medicale,  May 
31,  1883,  I,  p.  752.  Taylor:  Medical  Record,  May  24,  1884,  XXV,  p.  593. 
Knight:  New  York  Medical  Journal,  No.  24,  1884,  XXXIX,  p.  662. 

3  Bulkley:  Boston  Medical  and  Surgical  Journal,April  16,  1893, Vol.  128,  p.  345. 
*  Bosworth:  Medical  Record,  March  12,  1892,  XLI,  p.  300. 


234  INDICATION  FOR  OPERATION  ON  ADENOIDS 

more  emphatically  in  1892,  and  in  spite  of  many  protests  expressed 
from  time  to  tiin(>  that  this  is  an  inadequate  view  of  the  question, 
we  are  practically  today  on  that  basis,  both  as  to  tonsils  and 
adenoids.  The  descri})tion  of  the  symptoms  and  sequela^  of  the 
latter  have  received  no  essential  addition  since  Wilhelm  ^Meyer's 
first  article.  In  1S95  he  published^  a  review  of  the  various  aspects 
in  practice,  in  literature,  and  in  history,  which  the  subject  of  adenoids 
had  assumed  since  his  pai)er  in  18(JS.  It  is  scarcely  necessary  to 
do  more  than  refer  in  a  cursory  manner  to  some  of  these. 

Indication  for  Operation  on  Adenoids. — Guye,^  of  Amsterdam, 
first  in  1884  and  later  on  other  occasions,  emphasized  the  impor- 
tance of  the  effect  of  adenoids  on  the  mentality  of  children,  claiming 
there  is  a  specific  result  of  the  postnasal  ol)struction,  probal)ly  due 
to  interference  with  the  circulation,  which  is  evidenced  in  their 
inability  to  fix  their  attention  continuously  on  any  subject,  a 
mental  condition  which  makes  them  backward  in  school.  To 
this  symptom  he  gave  the  name  of  Aprosexia,  and  his  communica- 
tions excited  wide  interest.  Though  the  matter  had  been  empha- 
sized in  ^Meyer's  paper,  it  thus  received  from  Guye  additional 
emphasis.  Scarcely  a  paper  on  adenoids  has  been  published  since 
Meyer's  original  one  which  does  not  dwell  to  a  greater  or  less 
extent  upon  the  deformities  of  the  jaw  and  the  chest  caused  by 
the  presence  of  postnasal  adenoids.  As  to  the  jaw  there  is  refer- 
ence elsewhere  in  this  work  to  the  publications  of '  Grossheintz 
and  others,  which  goes  to  show  that  at  least  in  very  many  cases 
the  evidence  points  to  the  fact  that  the  jaw  shape  is  racial  or 
inherited.  The  adenoids  are  probably  the  sequence  and  not  the 
cause  of  high  palates  and  narrow  jaws.  The  paper  of  Lavrand^ 
deals  with  the  conventional  side  of  the  question  while  the  measure- 
ments given  by  Fracnkcl  of  Basle  in  a  dissertation'  in  1890  show 
that  there  are  other  factors  in  the  etiology  of  the  high  palatal  arch. 

Schwartz^  and  Siebenmann,*'  in  1897,  wrote  upon  the  relation  of 
cranial  form  to  palatal  form.  While  there  were  points  upon  which 
they  disagreed,  the  consensus  of  the  great  majority  of  such  observa- 
tions goes  to  establish  the  truth  of  the  assertion  that  the  high 
palatal  arch  is  not  the  sequence  of  postnasal   obstruction.     The 

1  Meyer:  Hospitals  Tidcnde,  February  0,  1895,  4,  R.  Ill,  p.  145.  Ref.; 
Internat.  Centralblatt  fi'ir  Laryngologic  und  Rhinologie,  1895,  XI,  p.  965. 

^  Guye:  Fifth  International  ('ongress  of  Hygiene  and  Demography,  1884, 
Tome  II,  p.  120  (French  ed.).  Deutsche  niedizinische  Wochensclirift,  No.  40, 
1888,  XIV,  p.  815;  British  Medical  Journal,  September  28,  18S9,  II,  p.  709; 
Practioner,  September  1,  1891,  XLVII,  p.  19S. 

'  Lavrand:  Revue  de  Laryngologie  et  de  Rhinologic,  No.  10,  August  15,  1894, 
XIV,  p.  687. 

*  Fraenkel:  Ref.;  Internat.  Centralblatt  fiir  Laryngologie  und  Rhinologie, 
1897,  XIII,  p.  839. 

^Schwartz:  Z(>itschrift  fiir  Ohreiilieilkunde,  1897,  X.XXII,  p.  (57. 

*Siebenmann:  Miinchener  medizinische  Wochenschrifl,  Xo.  36,  1897,  XLIV, 
p.  983. 


ANESTHESIA  IN  TONSIL  AND  ADENOID  OPERATIONS      235 

points  less  frequently  touched  upon  may  be  noted  briefly.  Bliss^ 
reported  in  1892  the  results  of  an  examination  of  415  young  deaf 
mutes  as  to  the  condition  of  the  nose  and  throat.  In  the  light  of 
subsequent  experience  it  does  not  appear  that  the  proportion  of 
large  tonsils  and  adenoids  was  greater  than  the  average  among 
them.  Among  the  reflexes  ascribed  to  the  presence  of  nasopharyn- 
geal adenoids,  eneuresis  in  children  was  repeatedly  discussed.'^ 
Lichtwitz  and  Sabrazes^  as  did  ^lasini  found  a  mild  leukocytosis 
in  children  with  adenoids,  diminished  haemoglobin,  and  increased 
lymphocyte  and  eosinophile  count.  Operation  tends  to  restore 
the  blood  condition  to  normal.  While  this  received  some  attention 
in  literature  it  has  been  for  the  most  part  ascribed  by  writers  to 
anaemia  incident  on  lack  of  oxygenation  of  the  blood.  ^Nlasini,^ 
in  1898,  claimed  that  he  had  obtained  a  rise  of  blood-pressure  in 
rabbits  by  the  injection  in  the  veins  of  a  watery  extract  of  the 
tonsils  of  dogs  and  calves,  from  which  he  reasoned  the  tonsils 
possess  an  internal  secretion.  His  experimental  work  was  devoid 
of  control.  An  increase  in  the  large  and  small  leukocytes  was  also 
observed. -^  Acute  inflammations  of  the  pharyngeal  tonsil  have 
been  rarely  discussed,  though  doubtless  they  often  occur.'' 

The  instruments  used  in  the  operation  for  the  removal  of  the 
faucial  tonsils  have  been  for  the  most  part  referred  to.  In  the 
removal  of  adenoids  they  have  been  practically  of  two  types,  that 
of  the  curette  and  that  of  the  forceps,  though  innumerable  of 
pattern.  ^Meyer's  ring  knife  and  the  index  flnger  armed  or  not 
with  the  steel  nail  were  the  representatives  of  the  former  type 
in  use^  in  1885,  when  Gottstein's  curette  came  into  use  and  Stork's 
choanal  forceps  began  to  be  modified  in  the  numerous  patterns 
which  exist  to-dav.^ 

Anaesthesia  in  Tonsil  and  Adenoid  Operations. — The  operation  at 
first  done  without  an  anaesthetic,  narcosis  began  to  be  advocateda 

1  Bliss:  Medical  News,  November  18,  1892,  LXI,  p.  576. 

^  Koerner:  Miinchener  medizinische  Wochenschrift,  No.  27,  1890,  XXXVII, 
p.  476.  Centralblatt  flir  klinische  Medizin,  No.  23,  1891,  XII,  p.  417.  Dioni- 
sio;  Gazz.  Med.  di  Torino,  June  1,  1893.  Otto:  St.  Petersburg,  medizinische 
Wochenschrift,  No.  38,  1893,  n.  f.,  X,  p.  345. 

'  Lichtwitz  and  Sabrazes:  Archiv  fiir  Laryngologie  und  Rhinologie,  1900, 
X,  278. 

*  Masini:  La  CHnica  Medica  Itahana,  May,  1898,  XXXVII,  p.  319. 

*  Masini  and  Genta:  Annali  di  Laringologia  ed  Otologia,  Jul}',  1900,  I,  p.  254. 
^  Beckmann:    Berliner  kUnische  Wochenschrift,  No.  50,   1902;  Miinchener 

medizinische  Wochenschrift,  No.  22,  1902,  XLIX,  p.  946.  Ausset  and  Dorion: 
Echo  Medicale  du  Nord.,  August  4,  1901,  V,  p.  353. 

'  Baber:  British  Medical  Journal,  March  21,  1885,  I,  p.  603. 

sGottstein:  Berhner  klinische  Wochenschrift,  No.  2,  1886,  XXIII,  p.  25. 
Loewenberg:  Deutsche  medizinische  Wochenschrift,  No.  16,  1886,  XII,  p.  265. 
Schlitz:  Centralblatt  fiir  Chirurgic  und  Orthopad.  Mcchanik,  July,  1886, 
Jahrg.  II,  No.  10,  p.  129.  Gradle:  Medical  Record,  December  10,  1887,  XXXII, 
p.  751. 

"  Hopmann:  Deutsche  medizinische  Wochenschrift,  No.  33,  1885,  XI,  p. 
572.    Michael:  Wkmcr  Khnik,  Heft  XII,  1885,  p.  363. 


236  HEMORRHAGE  AFTER  OPERATION 

at  this  time.  In  1S04  a  discussion  took  place^  at  a  meetins;  of  the 
London  Laryngolo<jical  Society  on  the  merits  of  the  difi'erent 
agents  of  anaesthesia  advisable  for  the  operation  of  the  removal  of 
adenoids.  Gradually  it  was  found  that  satisfactory  results  were 
not  obtained  without  some  form  of  anaesthetic  for  this  purpose, 
and  subsequently  it  has  grown  in  favor  even  for  tonsillotomy 
alone.  This  raised  the  question  of  the  position  of  the  patient  during 
operation.  All  possible  postures  of  the  body  have  been  suggested, 
and  it  is  still  a  matter  of  discussion  bv  larvngological  writers. 
Cocaine,  nitrous  oxide,  and  ethyl  chloride  gas,  chloroform  and  ether 
have  all  been  urged-  for  anaesthesia.  The  latter,  always  the  favorite 
in  America,  has  perhaps  grown  in  favor  abroad,  but  the  position 
of  the  patient  still  remains  largely  a  matter  of  individual  preference. 
AYith  the  spread  of  the  popularity  of  the  removal  of  tonsils  and 
adenoids  the  frequency  of  untoward  results  was  naturally  more 
and  more  marked.  Repeated  reports  of  alarming  hemorrhage 
following  the  removal  of  the  faucial  tonsils  are  found  in  the  ninth 
decade  of  the  nineteenth  century. 

Hemorrhage  after  Operation. — In  1S87  ZuckerkandF  dealt  exten- 
sively with  the  subject  of  hemorrhage  after  tonsillotomy,  with 
which  by  that  time  there  had  already  been  considerable  experience. 
He  discussed  at  length  the  literature  of  the  subject.  The  growing 
frequency  of  the  accident,  the  obstinacy  with  which  the  bleeding 
continues  and  the  difficulty  in  checking  it  gave  rise  about  this  time 
or  a  little  later  to  the  popularity  of  ignipuncture  of  the  tonsils. 
Wright,^  in  1890,  collected  a  bibliography  extending  over  twenty- 
five  years,  in  which  32  cases  of  alarming  tonsillar  hemorrhage,  with 
2  fatal  cases,  were  reported.  In  1902  Damianos  and  Hermann^^ 
collected  reports  of  150  cases  occurring  in  the  previous  sixty  years. 
Instruments  to  control  tonsillar  hemorrhage  were  invented  by 
Butts^  and  Proebsting.^  Cases  of  fatal  hemorrhage  after  tonsil- 
lotomy were  rarely  reported  unless  accompanied  by  the  remo^-al 
of  adenoids,^  and  subsequently  a  number  of  cases  with  fatal  termi- 
nation were  reported  after  the  removal  of  nasopharyjigeal  growths.^ 
Ilaymann^"  has  collected  an  extensive  bibliography  of  bleeding 
after  adenoid  operations;  many  of  the  cases  were  fatal,  forming 

1  Internat.  Centralblatt  fiir  Laiyngologie  unci  Rliinologic,  1894,  XI,  p.  270. 

2  British  Medical  Journal,  January  13,  May  5,  May  19,  1894,  I,  pp.  108,  996, 
1106.     Lancet,  Jan.  6,  13,  20;  Feb.  3,  1894,  I,  pp.  64,  122,  179,  300. 

5  Zuckerkandl:   Wiener  medizinische  Jahrbiichor,  1887,  Heft  VI,  p.  309. 

*  Wright:  New  York  Medical  Journal,  August  30,  1890,  LII,  p.  234. 

*  Damianos  and  Hermann:  ^^■iener  klinische  Wochenschrift,  No.  9,  1902,  XV, 
p.  225. 

*  Butts:  Medical  Record,  July  1,  1893,  XLIV,  p.  11. 

'  Proebsting:  Archiv  fiir  Laryngologic  und  Rhinologie,  1906,  XVIII,  386. 

8  Barkan:  Medical  News,  April  14,  1894,  LXIV,  p.  411. 

'  Beausoleil:  Journal  de  Mddecine  de  Bordeaux,  No.  23,  June  9,  1895,  XXV, 
p.  265.  Lunin,  Burger,  Goldsmith,  etc.:  Ref. :  Internat.  Centralblatt  fiir 
Laryngologie  und  Rhinologie,  1903,  XIX,  p.  582. 

"  Haymann:  Archiv  fiir  Laryngologie  und  Rhinologie,  1909,  Bd.,  21,  p.  15. 


SEQUELS  OF  ADENOID  OPERATIONS  237 

a  marked  contrast  to  the  cases  of  bleeding  after  the  removal  of  the 
faucial  tonsils,  but  singular  to  say,  the  latter  accident  has  attracted 
by  far  the  greater  amount  of  attention. 

Galvanocautery  in  Tonsillar  Hypertrophy. — One  consequence  of 
the  conservatism  excited  in  laryngologists  by  the  reports  of  alarm- 
ing tonsillar  hemorrhage  was  the  frequent  recommendation  of 
laying  open  the  tonsillar  crypts  with  galvanocautery  and  bistoury, 
and  in  1890  Botey^  used  the  galvanocautery  for  tonsillar  hyper- 
trophy. There  was  considerable  discussion  in  1892  in  America 
and  the  immediately  subsequent  years  as  to  the  cases  in  which 
ignipuncture  or  the  galvanocautery  snare  should  be  used  to  replace 
the  cutting  instruments.^  In  France,  Huguenin^  dealt  with  the 
same  subject.  Ruault*  proposed  removal  piecemeal  (morcellement) 
with  a  specially  devised  cutting  forceps.  Knight,*  Sendziak,*^ 
Lichtwitz^  recommended  galvanocautery  snares  for  the  removal 
of  tonsils.  Hopmann/  in  1899,  made  a  careful  and  extended  study 
of  the  anatomy  and  the  operative  procedures  in  the  subject  of 
adenoids,  with  an  historical  account  of  the  latter,  in  which  these 
and  other  matters  are  reviewed. 

Sequelae  of  Adenoid  Operations. — Among  the  few  sequelse  of 
adenoid  operations  we  may  mention  torticollis  and  the  recurrence 
of  the  growth.  Torticollis  as  a  complication  of  adenotomy  noted 
in  1894  by  Knight  and  INIcKernon  has  occasionally  been  reported 
since  then.^  In  1901  Gorke^o  ^jrew  attention  to  the  question  of 
the  recurrence  of  nasopharyngeal  lymphoid  tissue  after  operation 
and  to  the  fact  that  no  operation  ever  removes  all  the  lymphoid 
tissue  of  the  pharynx.  He  wrote  from  an  historical  standpoint. 
Xatier,^^  in  1903,  wrote  a  clinical  paper  on  the  same  subject,  pointing 
out  the  recurrences  were  often  more  apparent  than  real,  some  of 
the  symptoms  remaining  after  operation  or  recurring  because  of 
underlying  factors  not  always  dependent  on  the  lesion. 

After  1905  there  gradually  appeared  in  the  literature  dealing 

iBotey:  Revista  di  Ciencias  Medicas  di  Barcelona,  No.  10,  1890,  XVI,  p. 
293.    Ref.:  Internat.  Centralblatt  fur  Laryngologie,  1890-91,  VII,  p.  312. 

2  Knight:  Medical  Record,  March  12,  1892,  XLI,  p.  300.  Agramonte:  Ibid. 
Asch:  Ibid.  Delavan:  Ibid.  Robinson:  Ibid.  Loeb:  Medical  News,  March, 
19,  1892,  LX,  p.  321.  Knight:  Medical  Record,  May  14,  1892,  XLI,  p.  559. 
DeBlois:  Boston  Medical  and  Surgical  Journal,  October  12,  1893,  Vol.  129, 
p.  377. 

3  Huguenin:  Concours  Medical,  1892,  XIV,  p.  304. 
^  Ruault:  Union  M6dical,  1893,  Ser.  3,  LV,  p.  74. 

^  Knight:  Transactions  American  Laryngological  Ass'n,  1892,  p.  113. 

*  Sendziak:  Revue  de  Laryngologie,  1893,  XIII,  p.  129. 

'  Lichtwitz:  Medocine  Moderne,  January  30,  February  2,  1895,  VI,  pp.  65,  73. 

*  Hopmann:  Deut.  med.  Wochensch.,  1885,  XI,  p.  572. 

9  Knight:  Annals  of  Ophthalmology  and  Otology,  No.  2,  1894,  III,  p.  161. 
Thost:  Monatsschrift  fiir  Ohrenheilkunde,  1896,  XXX,  pp.  165,  224.  Ferreri: 
Archives  Internat.  d'otologie,  1904,  XVIII,  p.  744.  Neufeld:  Archiv  fur 
Laryngologie  und  Rhinologie,  1908,  XX,  p.  480. 

'^  Gorke:  Archiv  fiir  Laryngologie  und  Rhinologie,  1901,  XII,  p.  278. 

"  Natier:  Bull,  de  la  Societe  beige  d'otologie  et  de  laryngologie,  1903,  p.  199. 


238       NASAL  ANATOMY,  PHYSIOLOGY,  AND  PATHOLOGY 

with  hypertrojihied  tonsils  a  tendency  to  rep:ard  the  diffuse  or 
sunken  tonsil  as  more  apt  to  permit  the  entrance  of  infection.  This 
led,  in  America  at  first  and  chiefly,  to  greater  care  and  thoroufjhness 
in  removing  all  the  tonsillar  tissue.  By  means  of  finger  or  probe 
the  tonsils  were  separated  as  much  as  possible  from  the  surrounding 
tissue  and  removed  by  guillotine  or  snare.  Many  instruments 
were  invented  for  this  purpose.  Much  injury  was  done  to  sur- 
rounding tissues,  but  for  the  most  part  this  led  to  little  subsequent 
damage.  This  was  a  movement  in  laryngology  which  had  its 
inception  in  America  and  was  there  carried  perhaps  to  some  excess. 
The  literature  in  regard  to  it  is  voluminous  and  not  adapted  to 
orderly  review  nor  to  attempts  to  establish  any  claims  to  ])riority. 
While  the  movement  for  the  enucleation  or  more  thorough  removal 
of  the  tonsils  had  its  origin  in  North  America  the  procedure  soon 
found  favor  in  (Jreat  Britain  and  on  the  continent  as  testified  by 
many  articles  on  the  subject. 

Bone  and  Cartilage  in  the  Tonsils. — While  it  seems  desirable  to 
avoid  the  history  of  neoplasms  of  the  tonsils,  inasmuch  as  that 
leads  us  too  far  outside  of  our  s})ecial  province,  I  may  refer  to  the 
literature  of  bony  and  cartilaginous  growths  in  the  tonsils.  In 
the  literature  of  the  embryology  of  the  tonsils  mention  is  made 
of  the  inclusion  of  the  pharyngeal  arches  containing  cartilage, 
in  their  embryogenesis,  but  this  has  received  no  support.  Orth 
is  said  by  Deichert  to  have  noted  cartilage  and  bone  in  the 
tonsils  in  1893.  In  1895  Deichert'  made  a  special  study  of  the 
subject.  There  are  a  few  clinical  reports  of  bone  in  the  tonsils 
by  authors  who  supposed  its  presence  there  due  to  a  ])rolongation 
of  the  styloid  process  of  the  skull,^  but  for  the  most  part  there 
has  been  a  tendency  to  confine  the  subject  to  a  discussion  of  the 
phenomenon  as  one  of  metaplasia  or  of  embryonic  origin.  This 
can  be  found  fairly  well  set  forth  in  the  articles  of  Reitmann,^ 
Walsham/  Wingrave,^  Topfer,*^  Xosske,^  and  Ilalkin.Hhough  there 
have  been  many  subsequent  reports. 

NASAL  ANATOMY,  PHYSIOLOGY,  AND  PATHOLOGY. 

It  seems  at  first  glance  somewhat  strange  that  the  study  of 
nasal  disease  should   not  have  more  attracted  the  attention   of 

'  Deichert:  Virchow's  Archiv,  189.5,  Band  141,  p.  43.5. 

2  Stirling:  Atlanta  Medical  and  Surgical  Journal,  .July,  1890,  XIII,  p.  328. 
Richards:  Journal  American  Medical  Association,  Julj'  22,  1901,  XXXVII, 
p.  242. 

'  Reitmann:  Monatsschrift  fiir  Ohrcnheilkunde,  No.  8,  1893. 

^  Walsham:  The  Lancet,  August  13,  1898,  II,  p.  394;  British  Medical  Journal, 
October  22,  1898,  II,  p.  12.54. 

*  Wingrave:  Lancet,  1898,  II,  p.  750. 

*  Topfcr:  Archiv  fin-  Larvngologic  and  Rhinologio,  1900,  XI,  p.  1. 

'  Nosske:  Deutsche  Zeitschrift  fiir  Chirurgie,  1903,  Band  66,  Heft  .5-6,  p.  559. 

*  Halkin:  La  Presse  otolaryngolog.  beige.,  1905,  IV,  p.  433. 


NEGLECT  OF  NASAL  DISEASE  239 

physicians  even  before  the  discovery  of  the  laryngoscope.  Xasal 
operations  had  been  performed,  as  we  have  seen,  since  the  beginning 
of  medical  annals.  The  Hindus,  Hippocrates,  the  Arabians,  Aranzi 
and  his  followers,  were  accustomed  to  perform  anterior  rhinoscopy, 
and  one  would  naturally  think  some  device  would  ha\'e  been 
adopted  for  the  efficient  illumination  of  the  internal  nose.  We  have 
seen  that  Hippocrates  used  a  cannula  for  intranasal  cauterization, 
and  one  wonders  that  this  did  not  sooner  develop  into  a  nasal 
speculum. 

Nasal  Specula. — Guy  de  Cauliac  referred  to  a  device  of  Haly 
Abbas  which  we  have  noted,  a  "speculum  ad  Solem,"  which  may 
have  been  used  for  dilating  the  nostrils,  but  from  certain  passages 
in  the  Arabian  authors,  as  well  as  in  his  own  works,  I  cannot  but 
suspect  that  this  old  master-surgeon  of  the  Middle  Ages  misinter- 
preted his  perhaps  faulty  transcript  of  the  original  manuscript. 
Recent  scholarship^  has  unearthed  a  significant  passage  in  the 
works  of  Arnold  of  Villanova  (1240-1313).  If  one  will  turn  to  the 
place  indicated,-  one  will  find  the  author  describing  very  carefully 
and  minutely  the  symptoms  of  leprosy  and  the  physical  appearances 
of  the  face,  eyes,  etc.,  in  these  cases.  He  then  goes  on  to  say: 
"Likewise  they  are  to  be  known  from  the  wound  (ulcer)  existing 
in  the  nostrils,  aufl  these  should  be  examined  more  deeply;  for 
which  purpose  one  should  take  a  small  bifurcated  branch  of  wood 
like  a  forceps,  and  this  should  be  placed  in  the  nose,  opening  it,  and 
one  should  look  in  with  a  lighted  candle,  and  if  ulceration  or 
excoriation  is  seen  well  in  the  depths  of  the  nose,  that  is  a  reliable 
sign  of  leprosy  and  one  which  will  not  be  recognized  except  by  the 
well  instructed."  It  is  plain,  therefore,  that  one  of  our  modern 
forms  of  nasal  specula  was  formed  from  the  fork  of  a  tree  branch 
by  the  doctors  of  the  Dark  Ages,  and  we  incidentally  receive  another 
hint  as  to  obscurity  in  the  differentiation  of  disease. 

From  time  to  time  in  the  works  on  surgery  mention  may  be 
found  and  some  illustration  noted  of  nasal  specula,  chiefly  devised 
for  protecting  the  nose  from  the  incandescent  iron.  Thus  Garen- 
geot^  pictures  a  speculum  nasi  through  which  hot  cautery  irons 
may  be  thrust  to  sear  the  os  unguis  in  order  to  destroy  it.  "  Ainsi 
voila  son  usage  explique."  Dionis  in  his  work  on  surgery^  depicts 
an  instrument  which  is  still  occasionally  called  by  his  name,  and 
is,  in  metal,  practically  the  counterpart  of  the  de\ice  of  Villanova 
in  wood. 

Neglect  of  Nasal  Disease.— We  have  reviewed  the  separate  works 
of  Deschamps,  Cloquet,  and  Piorry  on  the  nose,  and  have  seen 
that   knowledge   of   intranasal   disease   was   fully  abreast   if   not 

1  Archiv  f.  I.arynsologie,  1900,  XI,  Heft  3,  p.  482. 

2  Opera  Arnoldi  (le  Villanova,  1509,  f.  214,  Signa  Leprosorum. 

^  Nouveau  Traite  des  Instruments,  Paris,  1727,  Tome  II,  p.  12. 

'  Cours  d'Operations  de  Chirurgie,  Paris,  1716,  p.  479,  Fig.  XXXVII,  E. 


240       NASAL  ANATOMY,   PHYSIOLOGY  AND  PATHOLOGY 

somewliat  in  advance  of  the  knowledge  of  larynfjeal  disease  up 
to  the  time  of  the  fruitful  labors  of  Czermak  and  Tiirck.  The  next 
fifteen  years  were  almost  exclusively  devoted  to  the  development  of 
the  knowledge  of  laryngeal  morbid  conditions  as  revealed  in  the 
laryngoscope  and  to  the  technique  of  operative  interference.  Jn 
the  first  edition  of  Solis  Cohen's  book  on  Diseases  of  the  Throat 
in  1872,  containing  more  than  200  pages,  scarcely  90  are  devoted 
to  diseases  of  the  nose.  In  1879  twenty  pages  were  added  in  the 
second  edition,  but  little  or  nothing  of  this  extra  space  was  devoted 
to  the  nose.  A  reference  to  anv  one  of  the  recent  text-books,  Lennox 
Browne's  last  edition  for  instance,  will  show  that  the  proportion 
has  been  more  than  reversed  in  the  thirty  years  of  the  active 
evolution  of  our  knowledge  of  the  normal  and  abnormal  states 
of  the  upper  air  passages.  In  the  first  edition  of  Cohen's  work, 
just  referred  to,  the  90  pages  are  taken  nj)  with  a  consideration  of 
epistaxis,  coryza,  ozsena,  the  nasal  douche,  anosmia,  foreign 
bodies,  nasal  polypi,  for  the  removal  of  which  the  use  of  the  nasal 
forceps  was  still  advised.  He  does  little  more  than  refer  to  affections 
of  the  accessory  sinuses.  Spencer  Watson  and  ]\Iichel,  in  1875, 
published  brochures  on  diseases  of  the  nose,  the  latter  being  trans- 
lated into  English  by  Shurly  in  187(),  but  it  was  after  1880  that 
the  impulse  to  the  more  exhaustive  study  of  intranasal  phenomena 
began,  and  in  another  ten  years  the  numl)er  of  journal  {)ubli('ations 
dealing  with  the  nose  and  nasopharynx  had  already  exceefled  in 
number  those  referring  to  the  larynx  and  air  tubes.  Notwith- 
standing the  enormous  increase  in  all  departments  of  the  literature 
of  our  specialty,  this  discrepancy  has  continued  to  gradually  become 
more  marked.' 

Reflex  Neuroses. — The  first  marked  evidence  of  this  awakening 
to  the  importance  of  nasal  phenomena  may  be  seen  in  the  history 
of  the  interest  aroused  in  reflex  nasal  neuroses.  Certainly  no  other 
subject  was  so  calculated  to  stimulate  inquiry  into  all  manner  of 
nasal  lesions.  How  grossly,  after  a  few  years,  this  subject  was 
exaggerated  and  distorted  is  apparent,  now  that  the  exaggeration 
is  decreasing.  Notwithstanding  the  fact  that  John  N.  ]\lackenzie- 
has  pointed  out  that  spasmodic  aflPections  of  respiration  had  been 
noted  by  Coelius  Aurelianus,  Galen,  and  many  other  subsequent 
writers  in  the  pre-rhin()scoj)ic  era,  ^'()ltolini•■'  was  the  first  to  note 
the  phenomena  at  a  time  when  the  local  conditions  in  the  nose 
could  be  carefully  studied  by  actual  inspection,  ^'oltolini  drew 
attention  to  the  intimate  connection  between  asthma  and  nasal 
polypi,  and  asserted  that  he  had  seen  the  asthma  disappear  on 
the  removal  of  the  polypi.     He  referred  the  idea  of  reflex  action 

'  A  reference  to  the  summary  of  the  literature  in  the  first  issue  of  each  year 
of  Semen's  Internationales  Centralblatt  fiir  Larj'ngologie  will  make  this  evident. 
2  Trans.  Amer.  Lar.  Ass'n,  18S(),  p.  1,54,  1887;  p.  102. 
'  ^'oltolini:  Die  Anwendungen  der  Galvanokaustik,  2  Aufl.,  Wien.,  1871. 


THE  ERECTILE  TISSUE  241 

from  the  irritation  of  the  mucosa  back  to  the  physiology  of  Johann 
jNIiiller,  and  we  have  seen  the  matter  discussed  in  the  lectures  of 
Marshall  Ilall,  in  183(3. 

Gross  Anatomy. — The  history  of  the  gross  anatomy  of  the  nose, 
internal  as  well  as  external,  is  the  history  of  anatomy  in  general. 
Knowledge  in  regard  to  it  had  been  very  largely  perfected  long 
before  the  rise  of  modern  laryngology.  The  work  of  Zuckerkanfll, 
beginning  about  1882,  and  that  of  Onodi  succeeding  it,  added 
much  of  detail  and  of  accuracy  to  the  already  large  fund  of  knowl- 
edge of  the  nasal  chambers  and  of  their  accessory  cavities,  but  all 
text-books  on  anatomy  before  that  period  contain  the  essentials 
of  it  from  the  stand-point  of  anatomy  in  general.  While  this  is  true 
of  the  anatomy  of  the  nose  and  the  nasal  chambers  proper,  the 
exactitude  which  exists  today  in  our  knowledge  of  the  accessory 
sinuses  is  largely  of  modern  origin.  This  is  referred  to  elsewhere 
under  the  heading  of  sinus  disease,  where  the  works  of  Zuckerkandl, 
of  Onodi  and  of  Killian  are  repeatedly  mentioned.  It  is  well  to 
mention  some  literature  in  regard  to  measurements  made  to  estab- 
lish the  relative  dimensions  of  the  nasal  chambers.  E.  Fraenkel, 
of  Basel,  in  a  dissertation  in  1896,  concluded  that  the  height  of  the 
palate  and  the  narrowness  of  the  jaws  were  racial  and  congenital 
characteristics  and  not  influenced  by  the  presence  of  adenoids  in 
childhood.  Grosheintz^  and  ^leisser,  on  the  other  hand,  in  1898, 
under  the  names  hypsistaphylia,  leptoprosopia,  and  chamseprosopia, 
contributed  extensive  articles  to  the  demonstration  of  the  influence 
that  high  palate,  narrow  or  wide  jaws  have  on  various  diseases  of 
the  nose  and  throat — atrophic  rhinitis,  adenoids  and  tonsils,  etc. 
Fifty  years  before  this  period  the  coincidence  of  the  high-arched 
palate  and  the  presence  of  enlarged  faucial  tonsils  had  been  noted, 
and  when  Meyer,  in  1868,  described  postnasal  adenoids,  attention 
was  more  actively  directed  to  this  coincidence,  and  for  thirty  years 
scarcely  a  treatise  was  published  on  the  subject  of  adenoids  and 
tonsils,  but  it  was  pointed  out  that  the  narrow  jaws,  like  the  narrow 
chests,  were  the  sequelae  of  the  lesion.  It  was  not  until  the  rise  of 
the  discussion  which  the  papers  of  Meisser  and  Grosheintz  inaugu- 
rated that  a  more  rational  view  was  taken  of  the  sequence  of  cause 
and  effect.  As  we  shall  subsequently  see,  the  coincidence  of  wide 
nasal  fossfe  and  atrophic  rhinitis  was  also  involved  in  the  same 
more  rational  anatomical  considerations. 

While  the  greater  part  of  our  existing  knowledge  of  gross  intra- 
nasal anatomy  goes  back  se\eral  centuries,  this  is  not  true  of  our 
knowledge  of  its  histology. 

The  Erectile  Tissue. — It  is  difficult  to  know  just  where  to  pick 
up  the  modern  story  of  our  knowledge  of  the  finer  structure  of 

1  Grosheintz  and  Meisser:  Archiv  fiir  Laryngologie  und  Rhinologie,  1898,  VIII, 
pp.  395  and  533. 

16 


242       NASAL  ANATOMY,   PHYSIOLOGY,  AND  PATHOLOGY 

the  nasal  mucosa.     The  most  natural  point  of  beginning,  in  view 
of  the  developments  of  modern  rhinology,  would  seem  to  be  at 
the  discove  y  of  the  erectile  nature  of  some  parts  of  it,  but  this 
seems  to  go  back  a  long  way,  even  perhaps  to  Schneider  himself. 
It  is  said  to  have  been  known  to  13cnedict  Kuppert^  in  1754.     It 
is  difficult  to  understand  exactly  what  this  ancient  conception  of 
the  nature  of  the  structure  of  the  mucosa  presenting  this  phe- 
nomenon was.    Long  after  the  correct  description  of  the  anatomy 
of  the  erectile  bodies  had  been  ])ul)lishe(l,  the  idea  prevailed  that 
their  erectile  nature  dej>ends  upon  the  loose  areolar  mesh-work. 
Even  in  text-books  of  a  comparatively  recent  period  will  be  found 
representations  of  experimental  states  produced  by  blowing  air 
or  injecting  liquids  not  into  the  bloodvessels,  but  into  the  loose 
connective  tissue.     This  artificial  em])hysema  may  be  produced 
anywhere  in  the  cada\'er  by  such  procedures,  and  it  seems  strange 
that  representations  of  that  should  luu'e  been  adduced  to  explain 
the  mechanism  of  turbinate  congestion  and  collapse.     It  was  not 
until  about  1850  that  it  began  to  be  understood  by  anatomists  that 
it  is  the  bloodvessels  which  are  the  chief  agents  in  its  causation. 
We  find  in  their  first  edition  that  Todd  and  Bowman-  recognized 
not  only  the  glands  with  which  their  names  are  associated,  but 
they  declared  that  the  thickness  and  sponginess  of  the  mucosa 
is  due  "chiefly  perha])s  to  the  presence  of  ample  and  capacious 
submucous  plexuses  of  both  arteries  and  veins,  of  which  the  latter 
are  by  far  more  large  and  tortuous."     They  also  recognize  that 
this  arrangement  tends  to   warm   the   inspired   air.     In   Ilyrtl's 
text-book,^  in  the  second  edition,  published  in  1851,  his  description 
of  nasal  anatomy  is  decidedly  inferior  to  that  of  the  English  authors 
whose  work  for  the  times  was  afimirable.     Hyrtl  recognized  the 
excessive  swelling  and  collapse  of  the  nasal  mucosa  but  did  not 
venture  on  an  explanation.     In   1853  Kohlrausch*  published  his 
classical  description  of  the  erectile  tissue  of  the  nasal  mucosa.    lie 
also  recognized  that  the  dilatation  of  these  vascular  channels  plays 
an  important  part  in  the  expression  of  the  secretions  of  the  glands 
lying  between  them  and  the  surface. 

For  about  thirty  years  there  was  little  advance  to  be  noted  in 
the  knowledge  of  the  vascular  supply  of  the  nasal  mucosa,  or  in 
the  minute  structure  of  the  stroma  in  which  it  lies,  and  with  which 
it  is  so  intimately  connected  in  the  performance  of  its  functions. 
So  intimate  is  this  physiological  and  anatomical  connection  that 
the   account   of  their  exploration   must   be   considered   together. 

'  See  Historical  Notes  on  the  Discovery  of  the  Nasal  Erectile  Tissue,  by  Dr 
John  N.  Mackenzie:  Boston  Medical  and  Surgical  Journal,  January  1,  1885 
CXII,  p.  1. 

2  Todd  and  Bowman:  The  Physiological  Anatomy  and  Physiology  of  Man, 
Philadelphia,  1850,  p.  391. 

'  Hyrtl;  Lehrbuch  der  Anatomic  des  Monschen.,  2  Aufl.,  Wien,  1851. 

*  Kohlrausch;  Archiv  f.  Anatomic,  Physiologic,  etc.,  Jahrg.  1853,  p.  149. 


THE  GLANDS  243 

In  the  first  edition  of  Zuckerkandl's^  work  on  the  anatomy  of 
the  internal  nose,  in  1882,  the  author  made  a  beginning  of  that 
minute  and  careful  study  of  the  subject  which  was  afterward 
expanded  in  his  later  editions  (1892  and  1893)  and  subsequently 
further  developed  by  many  writers  of  anatomical  and  pathological 
memoirs.  While  the  pathological  histology  of  hypertrophic  and 
atrophic  rhinitis  and  of  oedematous  nasal  polypi  is  more  fully 
developed  in  his  second  volume  it  still  is  far  from  a  complete 
expose  of  the  knowledge  even  then  extant  as  to  the  histology  of 
the  nasal  mucosa.  This  is  only  partly  remedied  in  his  larger 
volume  published  in  1893.  He,  however,  included  in  the  latter 
his  account  of  the  vascular  supply  of  the  mucous  membrane,  which 
still  remains  of  great  value  to  the  student.  This  description  of  the 
bloodvessels  was  first  published  in  1884." 

Bresgen^  largely  as  the  result  of  clinical  observation  was  inclined 
to  think  the  erectile  tissue  of  the  turbinate  bodies  the  result  of 
vascular  dilatation  in  acute  and  chronic  rhinitis,  in  other  words — • 
pathological — not  physiological  structures.  Coinciding,  as  the 
chief  development  of  the  ^'enous  sinuses  does,  with  that  period  of 
life  in  which  rhinitis  is  frequent,  this  idea  of  Bresgen,  which  may 
seem  so  strange  to  us  at  first  thought,  was  discredited  at  the  time 
of  its  publication  by  Zuckerkandl's  work.  On  second  thought  it  may 
easily  occur  to  us  that  the  advent  of  arlolescence  and  the  growth 
of  erectile  tissue  throughout  the  body,  in  the  lower  animals  as  in 
man,  may  well  have  as  an  adjuvant  a  process  of  intranasal  conges- 
tion which  we  are  accustomed  to  look  upon  as  pathological,  but 
which,  from  the  point  of  view  just  exposed,  might  be  looked  upon  as 
physiological. 

The  Glands. — Tofld  and  Bowman  harl  recognized  the  tubular 
glands  as  confined  largely  to  the  olfactory  region,  though  not 
exclusively  so.  They  moreover  recognized  that  they  were  analogous 
to  the  tubular  sweat  glands  of  the  skin.  In  1886  Dogiel^  contributed 
a  valuable  paper  to  the  anatomy  of  the  glands  in  the  olfactory 
region,  regarding  them  as  entirely  "  albuminous."  Paulsen^  regarded 
them  as  mixed  in  character,  but  this  was  by  \'irtue  of  their  possessing 
two  kinds  of  epithelial  cells,  one  excreting  a  watery,  albuminous 
secretion,  the  other  a  viscid,  mucoid  fluid.  He  observed  that  there 
were  apparently  two  morphologically  different  cells — one  small, 
cuboidal  and  granular,  the  other  large,  bottle-shaped,  and  having  a 

^  Zuckerkandl :  Normalc  und  pathologische  Anatomic  der  Nasenhohle,  etc., 
Wien,  1882. 

2  Zuckerkandl:  Denkschriften  der  Mathematisch-Natiirvvissenschaftlichen 
Klasse  der  Koniglichen  Akadeniie  der  Wissenschaften,  Wien,  Band  49,  18Si. 

^  Bresgen:  Deutsche  medicinische  Wochensclirift,  Nos.  35  and  36,  1885,  XI, 
p.  609. 

*  Dogiel:  Archiv  f.  mikroskop.  Anatomic,  1886,  XXVI,  p.  50. 

^  Paulsen:  Ibid.,  p.  307. 


244       NASAL  ANATOMY,  PHYSIOLOGY,  AND  PATHOLOGY 

cytoplasm  reacting  to  stains  for  mucin.  Stolir'  and  R.  Ileidenhain- 
had  already  in  a  study  of  jilandular  liist()loii;y  interpreted  such 
appearances  as  indicatin<;  the  vicarious  possibilities  of  cell  structure 
in  the  tubes  and  the  acini  of  the  same  glands.  Paulsen/  in  LSSS, 
showed  the  epithelium  of  all  the  accessory  cavities  to  be  supplied 
with  cilia.  lie  never  failed  to  find  glands  in  them.  He  showed 
beaker  cells  to  be  plentiful  everywhere.  Aschenbrandt,^  in  1885, 
bv  making  a  window  in  the  nasal  bones  of  rabbits  was  able  to  note 
the  secretion  from  the  glands  is  a  continuous  one,  excited  by  the 
contact  of  blotting  paper  to  the  mucosa  to  greater  activity  and 
accompanied  l)y  the  dilatation  of  the  capillaries.  He  also  made 
various  chemical  examinations  of  it.  He  showed  that  electrical 
excitation  of  the  s])henopalatine  ganglion  results  in  dilatation  of 
the  turbinate  bodies  and  of  the  septal  mucosa.  Degeneration 
of  the  mucosa  follows  extirpation  of  the  ganglion.  Stimulation  of 
it  results  in  the  simultaneous  flow  from  the  Bowman  glands  of 
watery  fluid  and  from  the  acinous  glands  of  mucus.  The  amount 
of  secretion  varies  with  the  degree  of  congestion  of  the  mucosa. 
He  had  previously  shown  that  the  nerve  centres  send  none  or  only 
feeble  stinuili  to  the  tracheal  glands  and  to  those  of  the  larynx. 
He  concluded  that  the  results  he  obtained  in  tlie  nose  were  due  to 
excitation  of  the  termination  of  twigs  of  the  trigeminus  in  the 
glandular  epithelium.  He  also  came  to  the  conclusion  that  the 
salivary  glands  were  supplied  by  the  same  nerve  as  the  serous 
glands  of  the  nose,  viz.,  the  second  branch  of  the  trigeminus, 
lirunn,^  in  1892,  made  a  contribution  to  the  literature  of  the  finer 
anatomy  of  the  human  intranasal  mucosa,  which  though  chiefly 
taken  up,  as  were  most  of  the  essays  on  the  microscopic  anatomy 
of  the  nose  before  this  date,  with  a  study  of  the  olfactory  perii)heral 
nerve  supply,  had  considerable  to  say  of  the  glands. 

Intra-epithelial  Glands. — In  1893  Zarniko*^  drew  attention  to  the 
existence  of  intra-epithelial  gland  formation  in  the  nasal  mucosa. 
In  the  publications  of  Ilyrtl,  Henle  and  of  some  of  the  earlier  histo- 
logists  there  is  mention  of  taste-buds  in  the  epithelium  of  the 
nasal  mucosa.  It  seems  probable  that  these  structures  Avere 
what  they  observed,  since  the  occurrence  of  taste-buds  similar  to 
those  of  the  tongue  and  connected  with  twigs  of  the  olfactory 
nerve  have  been  observed  only  in  certain  fishes  and  in  some  others 

1  Stohr:  Verhandlungon  dcr  i)hv.sikaliscli-nicdicinischcn  Gesellschaft  zii 
Wiiizburg,  1887,  XX,  1,  p.  5. 

2  R.  Heidenhain:  A  resume  of  the  question  in  its  broader  applieation  may 
be  found  with  eopious  references  in  INI.  Ileidenliain's  Phusma  und  Zelle,  1907, 
II,  p.  343  et  seq.  (Bardcleben's  Ilandl)uch  d.  Anat.,  Band  8). 

3  Paulsen:  Archiv  f.  mikroskop  Anatomic,  1888,  XXXIl,  p.  222. 

*  Aschenbrandt:  Monatsschrift  f.  Ohrenheilkunde,  etc.,  No.  3,  March,  1885, 
XIX,  p.  65. 

'  Brunn:  Archiv  f.  Mikroskop.  Anatomic,  1892,  Band  39,  p.  632. 
6  Zarniko:  Zeitschrift  f.  Ohrenheilkunde,  1903,  XLV,  p.  211. 


NASAL  SEXUAL    DEVELOPMENT  245 

of  the  lower  animals.  Boenninghaiis/  in  1895,  also  showed  the 
presence  of  small  glandular  acini  in  the  surface  epithelium  of  the 
chronic  inflamed  nasal  mucosa,  an  observation  subsequently 
confirmed  by  Glas-  and  others.  While  the  work  of  Cordes^  in  1900 
tended  to  confirm  the  findings  of  Boenninghaus  he  ascribed  the  struc- 
tures to  pathological  changes  in  the  ducts  of  glands  on  their  way  to 
the  surface  from  underlying  acini.  These  intra-epithelial  structures 
are  often  seen  in  histological  work  in  the  mucous  membranes. 

Smooth  Muscle  Cells. — Plerzfeld/  in  1SS9,  drew  attention  to  the 
fact  that  the  nasal  erectile  tissue  is  rich  in  organic  muscle  fiber. 
He  claimed  that  this  does  not  lie  free  in  the  stroma  but  that  it  is 
attached  to  the  vessel  walls.  He  showed  also  the  abundance  of 
elastic  tissue  in  the  stroma.  He  drew  attention  to  the  fact  that 
the  deep  veins  go  directly  from  the  venous  sinuses  to  the  channels 
in  the  underlying  bone.  He  showed  structure  resembling  erectile 
tissue  in  the  mucosa  of  the  nasal  septum.  Zuckerkandl  agreed 
with  Herzfeld  that  the  smooth  muscle  fiber  seen  in  the  stroma  of 
the  erectile  bodies  was  always  more  or  less  intimately  connected 
Avith  the  coats  of  the  bloodvessels.  Schieft'erdecker,^  in  1900,  did 
not  agree  with  this  statement,  and  ^Y^ight,'^  in  1910,  testified  to 
observing  isolated  smooth  muscle  fibers  in  the  stroma,  but  he  was 
inclined  to  think  that  in  the  course  of  the  development  they  had 
been  separated  from  the  vessels  by  the  growth  of  indifferent 
connective  tissue. 

Vascular  Mechanism. — In  1893  Zuckerkandl  published  the  first 
A-olume  of  the  second  edition  of  his  work.  This  greatly  enlarged 
and  made  more  exact  the  observations  previously  published.  He 
pointed  out  that  not  only  is  the  erectile  tissue  under  the  guidance 
of  the  vasomotor  elements  of  the  sphenopalatine  ganglia,  but,  as 
elsewhere  in  some  instances,  that  the  anatomical  arrangement  of 
arterv  and  vein  are  such  that  the  dilatation  of  the  artery  will 
compress  the  vein.  This  point  was  further  elaborated  by  Wright^ 
in  1895. 

Nasal  Sexual  Development. — John  X,  ]\Iackenzie^  and  Fliess^ 
and  manv  others  having  shown  the  clinical  evidences  of  connection 

1  Boenninghaus:  Archiv  f.  Laryngologie  und  Rhinologie,  1895,  III,  Heft  3, 
p.  372. 

2  Glas:  Archiv  f.  LarjTigologie  und  Rhinologie,  1904,  XVI,  p.  236,  full 
bibliography. 

•'  Cordes:  Archiv  f.  Laryngologie  und  Rhinologie,  1900,  X,  Heft  1,  p.  23. 

*  Herzfeld:  Archiv  f.  mikroskop.  Anatomie,  1889,  XXXIV,  p.  197. 

*  Schiefferdecker :  Handbuch  der  Laryngologie  (Heymann),  Wien,  1900,  III, 
p.  87;  bibliography  to  1896. 

^  Wright:  New  York  Medical  .Journal,  February  12,  et  seq.,  XCI,  p.  313. 

"  Wright:  American  Journal  of  the  Medical  Sciences,  May,  1895,  CIX,  p.  516. 

8  Mackenzie:  American  Journal  of  the  Medical  Sciences,  July,  1883,  Vol.  86, 
p.  106.  Johns  Hopkins  Hospital  Bulletin,  No.  82,  1898,  IX,  p.  10.  Journal 
of  Laryngology,  March,  1898,  XIII,  p.  109. 

'  Fliess:  Die  Beziehung  zwischen  Nase  und  weibliclicn  Geschlechtsorganen, 
1897. 


246       NASAL  ANATOMY,  PHYSIOLOGY,  AND  PATIIOLOOY 

between  the  nasal  mucosa  and  the  genital  a])paratus  in  man, 
Wright,'  in  1898,  drew  attention  to  the  anatomical  difference  in  the 
erectile  bodies  on  the  septum  of  an  ox  and  on  that  of  a  bull,  the 
castrated  animal  showing  the  erectile  tissue  markedly  less  developed 
than  the  animal  who  has  been  left  in  the  possession  of  his  genital 
organs. 

Elastic  Fibers. — Kubo,^  in  1907,  rlescribed  the  erectile  tissue  of 
the  nose  and  devoted  considerable  space  to  the  description  of  the 
elastic  fiber  in  it,  a  subject  also  treated  by  Wrighf  in  1910. 

All  this  work  was  of  course  in  its  development  governed  by  and 
parallel  with,  usually  preceded  by,  work  on  the  same  histological 
elements  in  other  organs  of  the  body  published  in  special  histological 
journals  or  text-books. 

Olfactory  Epithelium. — The  stu(h-  of  the  epithelium  of  the  nasal 
mucosa  in  its  connection  with  the  terminal  organs  of  olfaction 
was  the  aspect  of  histological  work  which  chiefly  interested  the 
earlier  workers  in  the  finer  anatomy  of  the  nasal  mucosa.  Todd 
and  Bowman  had  made  the  disco\ery  that  the  epithelium  in  the 
olfactory  regions  often  has  no  cilia.  Kolliker,*  in  1852,  denied  that 
this  was  so  for  man,  though  confirming  it  for  other  animals.  Eck- 
hard,^  in  1858,  confirmed  the  statement  for  rabbits,  but  declared 
that  the  frog  and  man  possess  a  ciliated  epithelium  in  the  olfactory 
regions.  Ecker,'''  in  1855,  made  a  study  of  the  minute  anatomy  of 
the  human  nasal  mucosa  and  descri})ed  not  only  the  columnar 
epithelium  of  the  olfactory  region,  but  the  peculiar  cells  which 
lie  between  them  which  he  recognized,  as  did  Eckhard  and  Schultze 
about  this  time,  were  the  terminal  organs  of  the  olfactory  nerve. 
While  thus  earh'  Ecker  and  lu-khard  described  the  olfactorv 
ej)ithelium  as  end  organs  of  the  nerve  of  olfaction,  Schultze  who 
had  made  contemporaneous  observations  published  some  years 
later  his  classic  work"  on  the  structure  of  the  nasal  mucosa  with 
especial  relation  to  the  olfactory  apparatus  in  men  and  animals. 
Luschka,*^  in  1864,  contradicted  the  observation  of  Schultze  who 
had  made  the  assertion  that  the  epithelium  of  the  olfactory  region 
has  no  cilia.    Welcker  also  is  said  to  have  made  this  observation. 

It  would  be  tiresome  and  un])rofitable  to  follow  further  the 
strife  over  these  points  of  the  distribution  of  ciliated  cells,  olfactory 

1  Wright:  Xow  York  Mcdioal  Journal,  Novombor  19,  1S98,  LXVIII,  p.  732. 

-  Kubo;  Archiv  f.  ]^aryngologie  und  Khinologic,  1907,  XIX,  p.  191. 

3  Wright:  New  York  Alcdical  Journal,  April  9,  1910,  XCI,  p.  729. 

^  Kollikcr:  Mikroskop.  Anatomic,  Leipzig,  lS.52-4,  2  abth.,  2  hiilfto,  p.  766. 

*  Eckhard:  Beitriigo  zur  Anal()nu(>  und  Fiij-siologic,  ]H5H,  I,  p.  77. 

*Eckcr:  Berichtc  iibcr  die  Vcrhandliuigcn'dcr  Cicscllscliaft  fiir  Beforderung 
der  Xaturwissenschaftcn  zu  Freiburg,  .\o.  12,  November,  18.55. 

^  Schultze:  Untcrsuehungen  iiber  den  Bau  der  Nasenschleinihaut,  namcntlich 
die  Struclur  und  Kndigungswei.se  der  Geruchsnerven  bei  dem  Alenschen  und 
den  Wirbelth  cren. 

^Luschka:  Centralblatt  fiir  die  medizinische  Wissenschaft,  No.  22,  May  21. 
1S64,  II,  p.  337. 


NASAL  EMBRYOLOGY  247 

terminal  cells  and  Bowman's  glands  through  the  works  of  Exner/ 
Waldeyer,-  Dogiel,'^  Suchannek/  ]\Ierkel,^  Disse,''  and  many  others. 
The  amount  of  literature  on  the  subject  for  twenty  years  was 
prodigious.  It  has  finally  emerged  that  while  there  is  an  olfactory 
zone  in  which  the  columnar  cells  are  not  ciliated  for  the  most  part 
and  a  respiratory  zone  where  for  the  most  part  they  are  ciliated, 
that  while  the  tubular  glands  are  for  the  most  part  confined  to 
the  olfactory  regions,  neverthless  there  is  a  border  zone  where 
ciliated  and  non-ciliated  cells,  tubular  glands  and  racemose  glands, 
mingled  with  olfactory  cells,  exist  together  in  irregular  distribution, 
not  only  in  the  pig,^  but  in  man.  Schultze  and  the  earlier  observers 
traced  the  olfactory  twigs  only  to  the  inferior  border  of  the  superior 
turbinate,  but  Kolliker  and  later  observers  have  traced  it  nearly 
to  the  level  of  the  lower  border  of  the  middle  turbinate  on  its 
medial   surface. 

Nasal  Embryology.  Balfour*  in  a  work  which  has  long  since 
become  classical,  wrote  in  1881,  exhaustively  on  the  embryology 
of  the  olfatory  organ  in  all  forms  of  animals.  It  was  on  the  material 
collected  for  this  work  that  for  the  most  part  ]MarshalP  based  his 
paper  in  1879.  Dogiel  (1.  c),  ]\Iorrill,^"  Disse,!^  all  wrote  valuable 
papers  on  the  embryogeny  of  the  nerve,  the  latter  giving  a  full 
bibliography.  Disse,  His,  and  others,  had  early  described  the 
embr^'ogenesis  and  anatomv  of  the  olfactorv  cells  and  of  the 
supporting  cells  which  make  up  the  less  superficial  layers  of  the 
region.  I  refer  elsewhere  to  the  work  of  Killian  and  of  others  in 
the  emljryogeny  of  the  nose  and  nasal  accessory  sinuses.  It  remains 
to  mention  a  more  recent  work  bv  Frazer,^-  who  described  the 
supporting  cells  which  make  up  the  less  superficial  layers  of  the 
epithelium  of  the  olfactory  region. 

In  the  first  decade  of  the  twentieth  century  the  interest  in  the 
olfactory  part  of  the  nose,  as  manifested  by  histologists,  was 
moderate,  while  previous  to  1900  the  attention  given  to  it  was 
almost  exclusive.  It  was  probably  owing  to  ignorance  of  any  other 
function  to  be  ascribed  to  the  nose  that  it  was  left  to  later  writers 
more  fully  to  develop  our  knowledge  of  other  structures  in  the 
nose.    Even  the  work  of  Kohlrausch  on  the  erectile  bodies  aroused 

^  E.xner:  Sitzungsberichte  d.  Math-nat.  Classe,  K.  Akad.  d.  Wiss.,  Wien, 
1872,  Band  65,  3  abth.,  Heft  I,  p.  7. 

^  Waldeyer:  Ai-chiv  fiir  Psychiatrie  und  Nervenheilkunde,  1884,  XV,  p.  279. 

^  Dogiel:  Archiv  fiir  mikrosckop.  Anatomic,  1887,  XXIX,  p.  74. 

^  Suchannek:  Archiv  fiir  mikroskop.  Anatomic,  1890,  XXXVI,  p.  375. 

*  Merkel:  Handbuch  der  topogi-aphischcn  Anatomic,  1891. 

6  Disse:  Anatomische  Hcfte  28-30,  1897,  IX,  p.  255. 

^  Alcock:  Anatomical  Record,  1910,  IV,  p.  123. 

^  Balfour:  A  Treatise  on  Comparative  Embryology,  2  Vols.,  London,  1880-81. 

'  A.  Alilncs  Marshall:  Quarterly  Journal  of  Microscopic  Science,  1879,  New 
Ser.,  XIX,  p.  300. 
'0  Morrill:  Journal  of  Comparative  Neurology,  1898,  VIII,  p.  180. 
11  Disse:  1.  c.  (1897). 
'2  Frazer:  Journal  of  Anatomy  and  Physiology,  1910-11,  XLV,  p.  347. 


248       NASAL  ANATO.yy,   I'lIYSlOUKiY ,   AND   PATHOLOGY 

little  interest  until  the  rise  of  the  modern  school  of  clinical  rhiii- 
olofjists.  ^'ery  little  advance  in  the  anatomical  knowledge  of  the 
olfactory  epithelium  has  })een  signalized  since  the  ])ul)licati()n  of 
Schultze's  monograj)!!,  so  exhausti\('  ai.id  exact  was  it,  but  nearly 
all  the  description  of  the  finer  histology  of  the  nasal  mucosa  has 
followed  our  clinical  api)reciation  of  the  fact  that  the  most  important 
functions  of  the  nasal  chambers  are  to  warm,  moisten  and  filter 
the  ins])ired  air  of  its  dust  and  bacterial  contents. 

Nasal  Lymphatics.^ — The  anatomy  of  the  lymphatic  supply  of 
the  nose  as  of  other  regions  of  the  body  goes  back  chiefly  to  the 
classical  work  of  Sapi)ey^  in  1S74.  In  the  following  year  Key  and 
Retzius-  made  the  observation  quoted  jn  every  rhinological  and 
anatomical  text-book  since  then,  that  the  lymph  spaces  of  the  nasal 
mucosa  communicate  with  those  of  the  meninges  through  the  crib- 
riform ])late.  Zuckcrkandl  repeating  some  of  their  experiments 
called  the  statement  into  some  doubt  in  1893,  but  on  the  whole  it 
has  been  upheld.  Kuttner^  for  the  external  nose  in  1899,  Most^ 
for  the  internal  nose  and  nasopharynx  in  1901,  Sieur  and  Jacob,^  in 
the  same  year  for  the  nasal  fosste  and  the  sinuses,  and  later  Andre, "^ 
Griinwald,"  Falconi,^  Poli,^  all  contributed  valuable  work  to  the 
elucidation  of  the  lymph  suj^ply  of  the  nose  and  its  adnexa.  In 
addition  to  the  work  directed  to  specific  points  in  the  histology  of 
the  nasal  chambers  more  or  less  covered,  though  by  no  means 
with  exhaustive  reference,  in  the  foregoing  pages,  there  has  been 
a  moderate  number  of  treatises  published  on  the  subject  as  a  whole, 
such  for  instance,  as  the  extensive  paper  of  ()j)pikofer,'''  in  1907, 
the  Atlas  of  Seifert  and  Kahn"  in  1895  and  above  all  the  valuable 
work  of  Schiefl'erdecker'-  in  1900. 

While  there  are  some  points  of  special  interest  in  the  history  of 
the  development  of  our  knowledge  of  nasal  neoi)lasms,  their  differ- 
entiation for  the  most  j)art  finds  its  place  in  the  general  history  of 
pathological  histology.  In  what  follows,  therefore,  no  attempt  at 
completeness  can  be  made  in  this  history  of  modern  rhinology,  so 

^  Sappey:  Anatoinie,  physiologic,  pathologic  dcs  vaisseaux  lymphatiques 
consideres  chez  rhomme  et  les  vcrtcbrcs,  Pari.s,  1874. 

^  Key  and  Retzius:  Studien  in  der  Anatomie  des  Nervensystems  und  des 
Bindcgewebes,  Stockholm,  l.S?^,  Band  I,  pp.  217-221. 

'  Kuttner:  Beitriige  zur  klinisehen  Chirurgic,  October,  1899,  XXV,  p.  3.3. 

■•  Most:  Archly  fiir  Anatomie  und  Physiologic,  Anatomische  Abt.,  1901,  p.  75. 

^  Sieur  and  Jacob:  Rechcrches  anatomi(]Ucs,  clinifiucs  et  ojicratoires  sur  les 
fosses  na.sales  ct  Icur  sinus,  Paris,  1901. 

•^  Andre:  Contribution  a  I'etude  dcs  Ivmphaliqucs  du  ncz  et  des  fosses  nasales, 
Th6se  de  Paris,  1905. 

'  Griinwald:  Archiv  fiir  Laryngologie  und  Hiiinologic,  1910,  XXIII,  p.  183. 

^  Faiconi:  see  Poll. 

"  Poll:  Archiv  fiir  Larj-ngologic  und  Rhinologic,  1911,  XXV,  p.  2.53. 

"•  Oppikofer:  Archiv  f.  Laryngologie  und  Rliinologie,  190tj,  XIX,  p.  28. 

"Seifert  and  Kahn:  Atlas  dcr  Ilistopathologie  der  Nase,  der  Alundrachen- 
hohle  und  des  Kchlkopfes,  \\'icsbadcn,  1895. 

'2  Schicfferdeckcr :  Ilcyiiiann's  Ilandbuch,  III,  1900,  p.  87. 


(EDEMATOUS  NASAL  POLYPI  249 

far  as  it  relates  to  tumors,  especially  true  tumors.  As  far  as  opera- 
tive procedures  are  concerned,  those  major  operations  involving 
extensive  exposure  of  the  nasal  chambers  and  their  accessory 
cavities  are  referred  to  in  the  account  of  sinus  disease,  but  these 
also  belong  to  another  domain  constituting  a  part  of  the  modern 
history  of  surgery. 

(Edematous  Nasal  Polypi. — The  history  of  nasal  polypus  is  so 
intimately  bound  up  with  the  history  of  the  histology  of  the  nasal 
mucosa  in  general  that  it  is  difficult  to  separate  the  two  in  modern 
rhinology.  The  conception  of  the  nasal  polypus  we  ha\e  followed 
down  to  the  time  of  ]\lorgagni.  It  remains  to  follow  it  during  the 
nineteenth  century.  In  the  surgery  of  Chelius^  as  late  as  1852 
we  find  that  he  regarded  the  nasal  polypus  as  a  local  infiltration 
of  the  mucosa  with  serum,  a  view  which  we  have  seen  prevail 
almost  since  the  downfall  of  the  Galenic  pathology.  Frerich^  is 
said  to  have  been  the  first  to  point  out  that  its  surface  is  covered 
by  epithelium  similar  to  that  of  the  surrounding  tissue. 

On  referring  to  an  early  (1854)  American  edition  of  Paget's 
"Surgical  Pathology,"  we  find  he  classes  nasal  polypi  among  the 
fibrocellular  tumors  (p.  38(3),  and  in  this  class  he  also  put  those 
growths  shortly  afterward  described  by  ^'irchow  under  the  name 
of  myxoma  in  the  "Krankhafte  Geschwiilste"  (ed.  1863,  p.  417), 
who  having  previously  described  myxoma  in  other  publications, 
dwelt  upon  the  relationship  it  bears  to  the  retrograde  metamorphosis 
of  fatty  tumors  and  of  fat  tissue,  being  frequently  therefore  found 
in  connection  with  lipomata.  He  states  that  myxoma  "in  adults 
is  relati^'ely  infrequent,  even  in  the  atrophic  metamorphosis  of 
fat  tissue  in  the  mucous  membranes."^  I  need  only  refer  in  passing 
to  the  remarkable  mistake  made  by  Billroth'*  in  ascribing  the 
structure  usually  found  in  rectal  polypi  to  those  found  in  the 
nasal  cavity.  He  says  he  examined  twenty-three  cases  of  nasal 
polypi,  and  they  were  nearly  all  adenomatous  in  structure. 

It  needs  only  a  reference  to  a  few  of  the  modern  text-books  on 
pathology  to  show  that  the  definition  of  Mrchow  as  to  myxoma, 
in  spite  of  much  well-grounded  criticism,  is  still  universally  accepted, 
and  yet  in  not  a  few  of  them  has  crept  the  idea  that  the  structure 
of  the  nasal  polyp  conforms  to  it.    Billroth-'  and  Cornil  and  Ixanvier'' 

1  Chelius:  Handbuch  der  Chirurgie,  7th  edit.,  Heidelberg,  1852,  Band  II, 
p.  530. 

-  Frerich:  De  Polyporum  Structura  Penitore,  184.3. 

2  Virchow  (Virchow's  Arch.  f.  path.  Anat.,  1900,  Band  162,  p.  163,  Heft.  1), 
remarks  incidentally  as  to  this  matter:  "Es  ist  ein  blosses  Spiel  mit  Worten, 
wenn  man  junge  pathologische  Zellen  und  Gewebc  embryonale  nennt."  Some 
account  of  the  question  of  the  doubt  as  to  Virchow's  classification  of  nwxoma 
may  be  readily  found  in  Councilman's  article  on  "Myxoma"  in  Wood's  "Refer- 
ence Hand-book  of  the  Medical  Sciences." 

^  Bilh-oth:   Ueber  den  Ban  d(n-  Schleimpolypen,  Berlin,  1854. 

5  Billroth:  Surgical  Pathology,  1882. 

•*  Cornil  and  Ranvier:  Manuel  d'histologie  pathologique,  2  ed.,  Paris,  ISSl. 


250       NASAL  ANATOMY,   PHYSIOLOGY,  AND  PATHOLOGY 

follow  liim  explicitly.  Birch-IIirsohfekP  speaks  of  nasal  polypi  as 
soft  fibromata  or  myxofihromata.  Evidently  he  had  no  experience 
of  his  own  with  these  growths,  because  in  his  description  of  myxoma 
he  describes  them  in  the  sense  of  the  others.  He  misquote(l  Hop- 
mann,  who  as  we  shall  see  presently  directly  repudiated  the  idea 
of  myxoma  of  the  nose.  Weichselbaum-  gave  a  characteristic 
wood -cut  and  the  usual  description  of  true  myxoma.  Ziegler^ 
says  that  the  nasal  polypi  are  made  up  of  cedematous  connective 
tissue  and  mucous  tissue,  and  must  therefore  be  ranked  among 
the  fibromata  and  myxomata,  but  he  differs  in  no  way  from  other 
pathologists  in  his  description  of  the  latter,  which  are  always 
combined,  he  says,  with  the  histological  forms  of  other  tumors. 
Delafield  and  Prudden,  in  the  1892  edition  of  their  "Patliological 
Anatomy,"  state  that  it  is  frequently  difficult  to  distinguish  between 
the  two;  but  in  the  illustration  they  give  of  the  structure  of  a 
mucous  polyp  of  the  nose,  there  is  no  resemblance  to  the  picture 
they  give  of  a  higher  amplification  as  typical  of  myxoma.  In  later 
editions  this  is  corrected. 

When  we  attempt  to  find  who  was  responsible  for  the  introduc- 
tion of  the  term  "myxoma"  into  nasal  pathology,  we  are  baffled 
by  the  apparent  insidiousness  of  the  process.  It  seems  to  have 
crept  in  through  its  use  by  WTiters  who  are  either  unfamiliar  with 
the  myxoma  of  Virchow,  or  else  unfamiliar  with  the  histological 
details  and  the  pathogenesis  of  nasal  polypi. 

The  first  mention  of  myxoma  occurring  in  the  nose  which  I 
have  been  able  to  find  is  a  report  by  S.  W.  Gross  in  1871.^  We 
find  here  the  "myxoma"  error  in  full  bloom. 

A  glance  at  the  text-books  on  the  nose,  which  began  to  appear 
first  a  third  of  a  century  ago,  convinces  one  that  the  term,  if  not  the 
c-onception,  of  Virchow  was  well  established  in  the  literature  of 
the  subject.  Michel,  indeed,  who  published  in  1875  the  first 
extended  work  of  modern  date  on  the  diseases  of  the  nasal  ca^•it^', 
did  not,  so  far  as  I  can  see  from  the  translation  of  Shurly,  speak  of 
the  polypi  as  myxomatous,  and  his  conception  of  their  etiology 
and  pathogenesis  does  not  coincide  with  the  view  of  there  l^eing  a 
new  growth  of  tissue.  Cohen,  whose  work  first  appeared  in  1879, 
accepted  the  classification  of  myxoma.  Stork,  in  1880,  did  not  use 
the  word  in  connection  with  them,  but  in  Bosworth's  first  edition 
in   1881,  they  are  so  classified,  Zuckerkandl^  very  curiously  fell 

'  Birch-Hirschfeld :  Lehrbuch  der  ixathologischen  Anatoniio,  1887,  Vol.  II, 
p.  381;  1889,  Vol.  I,  p.  151. 

^  ^yeichselballm :  Crundriss  der  pathologischen  Histologie,  Leipzig,  1892. 

'  Ziegler:  Lehrbuch  der  allgemeinen  Pathologic  und  der  pathologischen 
Anatomie,  Jena,  1895,  Vol.  II,  p.  625;  1895,  Vol.  I,  p.  397. 

*  Gross:  Transactions  Pathological  Society  of  Philadelphia,  1871-73,  IV,  p. 

*  Zuckerkandl:  Normale  und  pathologische  Anatomie  der  Nasenhohle,  Wien, 
1882,  p.  76. 


(EDEMATOUS  NASAL  POLYPI  251 

intd  the  serious  error  of  Billroth,  quoting  him  with  assent  in  saying 
thev  are  adenomatous,  but  he  makes  no  reference  to  them  as  mvxo- 
matous.  Beverley  Robinson,  in  his  treatise  on  "Nasal  Catarrh," 
the  second  edition  of  which  appeared  in  1885,  referred  to  nasal 
polypi  as  myxomatous.  ■\Iorell  ^lackenzie  began  his  chapter  on 
nasal  polypi  by  saying  they  are  new  formations  nearly  always  of 
a  myxomatous  character.^  I  will  not  pursue  text-book  literature 
into  more  recent  time.  Suffice  it  to  say  that  in  nearly  all  of  the 
special  works  on  the  nose  this  error  in  nomenclature,  if  not  in 
conception,  still  exists. 

It  is  to  Hopmann  that  we  are  indebted  for  the  first  serious 
attempt  to  dispel  it.^  In  1885  he  refuted  not  only  the  mistake 
of  Billroth  as  to  their  adenomatous  nature,  but,  quoting  from  the 
German  translation  of  ^Mackenzie's  book,  he  denied  the  latter's 
assertion  as  to  the  myxomatous  character  of  nasal  polypi.  They 
are,  he  asserted,  to  be  looked  upon  as  soft,  oedematous  fibromata. 
Chiari,  in  1887,  said :  "  On  the  ground  of  an  histological  examination 
of  twenty-three  nasal  polypi,  polypoid  hypertrophies,  and  papillo- 
mata,  I  came  to  the  conclusion  that  also  in  nasal  polypi  it  was 
only  a  matter  of  serous  infiltration  of  a  hypertrophy  of  the  mucosa." 
In  many  subsequent  papers  this  view  has  been  incontrovertibly 
established — most  conclusively,  I  think,  by  Hajek'^ — and  it  has 
been  urged  in  this  country  by  Wright^  and  others.  A  paper  dealing 
with  this  subject  exhaustively  was  that  of  Cordes''  in  1900.  There 
is  very  little  to  be  found  in  it  which  had  not  been  stated  previously 
bv  other  observers,  but  it  is  a  verv  satisfactor\'  confirmation  of 
much  work  done  by  others,  the  publications  of  which  are  scattered 
through  rhinological  literature. 

Woakes,^  in  1885,  believed  that  nasal  polypi  accompany  and 
are  caused  by  an  inflammation  advancing  from  the  mucosa  through 
the  periosteum  to  the  bone  structure  itself.  He,  at  least  as  early 
as  that,  plainly  traced  the  affection  to  an  inflammatory  condition. 
Wright/ in  1897,declared  that  myxoma  in  the  sense  of  the  histologists 
does  not  occur  in  the  nose.  This  has  been  practically  upheld  since 
the  proper  differentiation  was  accepted.  In  1901  Hajek  and  Polyak^ 
reported  a  nasal  growth  which  they  seemed  to  have  good  reason 

^  Mackenzie:  A  Manual  of  Diseases  of  the  Throat  and  Nose,  N.  Y.,  1884, 
Vol.  2,  p.  350. 

-  Hopmann:  Monatsschrift  fiir  Ohrenheilkunde,  June,  1885,  XIX,  p.  161. 
It  is  less  clearly  combated  in  his  paper  in  Virchow's  Archiv  f.  path.  Anat., 
1883,  XCIII,  p.  213. 

3  Hajek:  Archiv  f.  Laryngologie,  etc.,  1896,  Band  IV,  Heft  3,  p.  277. 

*  Wright:  New  York  Medical  Journal,  November  4,  1893,  LVIII,  p.  521. 

5  Cordes:  Archiv  f.  Laryngologie,  etc.,  1900,  XI,  Heft  2,  p.  280. 

«  Woakes:  British  Medical  Journal,  April  4,  1885,  I,  p.  701. 

'  Wright:  Transactions  American  Laryngological  Association,  1897,  p.  61. 
Archiv  f.  Laryngologie,  etc.,  1897,  VII,  p.  96. 

^  Hajek  and  Polyak:  Ai-chiv  f.  Laryngologie  und  Rhinologie,  1910,  XXIII, 
p.  43. 


252       NASAL  ANATOMY,  PHYSIOLOGY,  AND  PATHOLOGY 

to  believe  was  a  true  myxomatous  tumor,  reporting  it  as  a  myxoma 
lympliaugiectatieum.  If  so,  as  they  remark,  it  is  probably  a  unique 
case.  It  was  a  deeply  seated  growth  of  the  base  of  the  skull  dis- 
torting the  bony  nasal  frame-work  in  a  patient  who  died  of  tuber- 
culous disease  of  the  lungs.  A  paper  was  published  by  Okada^ 
on  the  histology  of  nasal  polypi  in  which  considerable  emphasis 
was  laid  ui)()n  what  he  called  mucous  degeneration  of  the  surface 
epithelium.  Wright,-  in  189S,  described  the  occurrence  of  hyaline 
bodies  in  nasal  polypi,  especially  in  adenomata,  which  he  regarded 
as  due  to  degeneratiA'e  processes  which  result  in  the  overgrowth  of 
certain  of  the  granules  in  some  of  the  cell  bodies  of  the  connective 
tissue.  Kalischer''  reported,  in  1895,  having  frequently  found 
nerve  fibers  in  oedematous  nasal  polyi)i. 

Nasal  Papillomata  and  Papillary  Hypertrophies. — There  has  been  in 
the  modern  history  of  laryngology  another  more  exact  differentiation 
in  nasal  pathology  since  the  publication  of  Billroth,  of  which  we 
must  take  account.  His  declaration  that  all  nasal  ])olypi  are 
adenomatous,  as  we  have  seen,  found  refutation  in  the  work  of 
Hopmann.  The  latter  author  was  less  happy  in  his  contribution 
to  the  literature  of  another  class  of  nasal  growths.  Hopmann,'* 
in  1883,  described  a  number  of  cases  of  papilloma  of  the  nose  as 
observed  by  him  and  studied  by  him  microscopically.  These 
nearly  all  occurred  on  the  inferior  turbinated  l)one.  Supported 
by  the  half-admission  of  ]\Iorell  ]\lackenzie,'^  Schech,*'  Schaefi'er,' 
Krause,^  ]\Ioldenhauer,^  Chiari,!"  Juraz,"  and  Bayer,!^  this  mistake 
persisted  in  the  literature  of  nasal  pathology  to  some  extent  for 
a  number  of  years.  Lacoarret'^  and  Moure'^  in  1889  protested 
against  the  idea,  declaring  such  tumors  were  merely  hypertrophies 
of  the  mucous  membrane  or  granulation  tissue.  As  pointed  out  by 
Wright,^^  in  1891,  the  mistake  was  one  more  of  nomenclature  than 

'  Okada:  Archiv  f.  Laryngologie  und  Rhinologie,  1898,  VII,  p.  204. 
2  Wright:  American  Journal  of  the  Medical  Sciences,  October,  1898,  CXVI, 
p.  445. 

^  Kalischer:  Arch.  f.  Laryngologie,  etc.,  1895,  Vol.  2,  No.  2,  p.  269. 

*  Hopmann:  Virchow's  Archiv  f.  path.  Anat.,  1883,  XCllI,  p.  213. 

^  Mackenzie:  Diseases  of  the  Throat  and  Nose,  1884,  Vol.  II,  p.  377. 
"  Schech:  Krankheiten  der  Mundhohle,  etc.,  Leipzig,  1888,  p.  267. 
^  Schaeffer:  Quoted  by  Hopmann  in  ^^■ien.  medizinische  Presse,  1883,  XXIV, 
1227. 

*  Krause:  Quoted  by  Hopmann  in  Wien.  medizinische  Presse,  1883,  XXIV, 
1227. 

'  Moldenhauer:  Quoted  bv  lloi)mann  in  Wien.  medizinische  Presse,  1883, 
XXIV,  1227. 

^°  Chiari:  Revue  mensuelle  de  laryngologie,  March,  1880,  No.  3,  VI,  p.  121. 

"  Juraz:  Die  Ivi-aiikheiten  der  obcrcn  Luftwege,  Heidelberg,  1890,  p.  90. 

'-  Bayer:  Quoted  by  Hopmann  in  Wien.  medizinische  Presse,  1883,  XXIV, 
1227. 

"Lacoarret:  Revue  mensuelle  de  laryngologie,  No.  17,  1889,  IX,  et  seq.,  p. 
497. 

"  Moure:  Ref.  in  Centralblatt  fiir  Laryngologie,  1889-90,  VI,  p.  324. 

"  Wright:  New  York  Medical  Journal,  December  26,  1891,  LIV,  p.  711. 


NASAL  PAPILLOMATA  AND  PAPILLARY  HYPERTROPHIES    253 

of  pathology.  It  has  long  since  become  firmly  established  that 
papillary  hypertrophy  of  the  nasal  mucosa,  such  as  often  occurs 
on  the  lower  antl  posterior  aspects  of  the  inferior  turbinate  bones 
has  a  structure  differing  entirely  and  a  genesis  differing  very 
much  from  that  of  a  papilloma  or  fibroma  papillare  in  the  sense  of 
Virchow.  This  was  more  explicitly  set  forth  by  Wright^  in  1895. 
A  number  of  cases  of  true  papilloma  in  the  nose  have  been  reported. 
Unlike  myxoma,  papilloma  occurs  in  the  nose  but  not  with  the 
frequency  which  we  would  be  compelled  to  admit  had  Hopmann's 
nomenclature  been  accepted.  Kiesselbach-  reported  cases  of 
papillary  growths  under  the  name  of  epithelioma  papillare  in 
conformance  with  the  nomenclature  and  conception  of  Billroth 
and  Hopmann — they  being  what  we  are  now  accustomed  to  regard 
as  papillary  hypertrophies.  For  a  few^  years  both  this  term  and 
that  of  Hopmann,  confounding  papillary  hypertrophies  with  true 
papillomata  were  used,  causing  much  uncertainty  in  the  literature 
of  nasal  pathology.  Arrowsmith^  in  reporting  a  case  of  true  papil- 
loma of  the  nose  collated  a  bibliography  of  fifteen  reports  and 
Newcomb*  extended  the  bibliography  in  the  report  of  another 
case  in  1901.  He  referred  to  nine  cases  mentioned  in  literature 
since  Arrowsmith's  bibliography  was  published.  For  the  most 
part  since  that  date  the  proper  differentiation  has  been  made  by 
observers  of  cases.  Chavanne,*  in  1907,  gave  a  very  good  account 
of  papillomata  of  the  nasal  fossse  with  a  summary  of  many  of  the 
cases  hitherto  reported  and  an  extensive  bibliography.  In  1897 
Hellmann*^  wrote  an  article  on  the  subject  of  nasal  papilloma  and 
their  transformation  into  carcinomata,  from  Hopmann's  standpoint, 
separating  the  cases  of  papilloma  into  hard  and  soft.  There  is  no 
appreciation  of  the  proper  histological  differentiation  between 
true  papilloma  and  papillary  fibroma  or  papillary  adenoma.  His 
paper  contains  a  large  but  not  exhaustive  bibliography  of  previous 
work.  He  has  had  no  support  in  his  belief  that  there  is  a  frequent 
malignant  transformation  of  cases  of  hard  papillomata  into  epi- 
theliomata,  but  in  much  of  the  German  literature  the  true  papillo- 
mata became  known  as  "hard"  papillomata  and  Hopmann's 
papillomata  or  papillary  hypertrophies  were  spoken  of  as  soft 
papillomata,  a  quite  inadequate  distinction.  Notwithstanding 
occasional  evidence  of  the  unfortunate  results  of  this  confusion  in 
nomenclature,  the  essential  difference  in  the  nature  of  the  true 
and  the  false  nasal  papillomata  is  at  present  well   understood. 

1  Wright:  New  York  Medical  Journal,  October  13,  1894,  LX,  p.  453 
^  Kiesselbach:  Virchow's  Archiv  f.  path.  Aiiat.,  1893,  Band  132,  p.  371. 
^  Arrowsmith:  The  Laryngoscope,  1897,  III,  p.  283. 

■*  Newcomb:  Transactions  of  the  American  Laryngological  Association,  1901, 
p.  130. 

*  Chavanne:  Annales  des  maladies  de  I'Oreille,  etc.,  August,  1907,  XXXIII, 
Pt.  2,  p.  113. 

*  Hellmann:  Archiv  fiir  Laryngologie  und  Ilhinologie,  1897,  \T,  p.  171. 


254       NASAL  ANATOMY,   PHYSIOLOGY,  AND  PATHOLOGY 

Verneuil.'  in  ISSO  reported  a  case  of  what  appeared  to  be  a  benif!;n 
nasal  jjapillonia  which  repeatedly  recurred,  and  in  spite  of  extensive 
operations  for  its  removal,  continued  to  recur  over  the  whole  of  the 
nasal  mucosa.  In  1908  Wright-  referred  to  two  similar  cases 
coming  under  his  own  observation.  There  was  persistent  surface 
epithelial  proliferation  and  extension  without  infiltration  lasting 
many  years  unchecked  by  radical  operation.  Histologically  these 
cases  were  essentially  benign,  and  clinically,  so  far  as  was  known, 
they  did  not  result  fatally,  though  their  persistence  and  their 
recurrence  were  the  sources  of  much  suffering  on  the  part  of  the 
patients. 

Nasal  Adenomata  and  Papillary  Hypertrophies. — The  connection 
between  papillary  hypertrophies  and  adenomata  in  the  nose  and 
their  gradual  merging  into  one  another  across  an  indefinite  boundary 
line  was  pointed  out  by  Wright,^  in  1897,  who  referred  to  the  work 
of  Billroth,  and  reported  cases  some  of  which  were  plainly  on 
one  side  of  the  line  and  some  on  the  other.  If  this  difficultv  of 
differentiation  has  been  felt  in  the  classification  of  adenomata  and 
of  inflammatory  papillary  hypertrophies,  in  rhinological  practice, 
it  has  been  felt  largely  as  a  question  of  academic  interest  only. 
Quite  a  different  matter  has  been  the  question  of  differentiation 
between  benign  and  malignant  adenomata.  It  is  no  doubt  true 
if  we  rule  out  those  cases  manifestly  of  inflammatory  origin  and 
those  cases  whose  subsequent  histories  prove  them  to  be  malignant, 
adenomata  in  the  nose  is  of  rare  occurrence.  Such  is  the  con- 
clusion of  Saitta,*  who  concluded  that  pure  adenoma  is  very  rare 
indeed;  the  mixed  form  is  more  common,  though  they  are 
separate  indi\idual  growths  and  are  by  no  means  secondary 
to  inflammatory  hypertroj)hy.  Though  they  ha^■e  no  specific 
symptoms  distinguishing  them  from  other  growths,  and  though 
they  are  of  benign  nature,  he  points  out  the  readiness  with  which 
they  become  malignant,  yet  advised  against  premature  operation. 
Citelli  and  Calamida,^  in  1902,  referred  to  several  cases  of  growths 
in  the  nose  which  they  classified  as  epitheliomata.  They  seem  to 
belong,  however,  among  the  papillary  adenomata  and  the  papillary 
hypertrophies. 

Angiomata  and  Bleeding  Septal  Polypi. — The  salient  points  of  in- 
terest in  the  subject  of  vascular  n(H)])lasms  of  the  nasal  chambers 
has  been  the  nature  of  the  Iiyi)ertropliy  of  the  posterior  ends  of  the 
inferior  turbinated  bodies  and  the  frequency  with  which  angiomata 
are  seen  on  the  septum.    It  is  quite  well  understood  that  the  former 

1  Verneuil:  Bull,  et  IVI6m.  de  la  socicld  de  Chirurgio  de  Paris,  1886,  XII,  p.  658- 

=  Wright:  The  Laryngoscope,  February,  1908,  XVIII,  p.  81. 

'  Wright:  New  York  Medical  Journal,  November  13,  1897,  LXVI,  p.  653. 

*  Saitta:  Archivii  Italiani  di  Laringologia,  etc.,  1897,  fasc.  4,  XVII,  p.  1.57. 

*  Citelli   and   Calamida:    Arrhiv   fiir   Laryngologie   und   Jihinologie,    1902, 
XIII,  p.  273. 


NASAL  CYSTS  255 

are  not  to  be  classed  among  the  true  tumors.  Neumann/  in  1861, 
contributed  to  the  knowledge  of  cavernous  tumors  a  description  of 
the  gross  and  minute  appearances  of  a  vascular  growth  removed 
from  the  nose,  but  as  there  is  no  indication  of  its  site  of  intranasal 
attachment  and  origin  the  report  has  only  historical  interest. 
Virchow,-  in  1863,  was  in  doubt  if  the  hypertrophies  at  the  posterior 
end  of  the  inferior  turbinated  bodies  should  be  called  angiomata 
or  not,  calling  attention  to  Neumann's  description  of  the  condition.^ 
As  in  many  other  fields  the  father  of  the  modern  nomenclature  of 
tumors  was  at  a  loss  to  draw  the  line  between  the  true  and  the 
false.  Biological  science  as  it  ad\'ances  is  continually  showing 
the  arbitrary  nature  of  such  divisions.  IMorell  INIackenzie,^  in  1884, 
and  Lange,^  in  1892,  had  referred  to  such  cases,  but  for  thirty  years 
vascular  tumors  of  the  anterior  nares  had  been  spoken  of  as  rare 
phenomena.''  As  a  matter  of  fact  they  are  the  most  common  of 
all  the  benign  neoplasms  of  the  nasal  fossse  which  have  any  claim 
to  be  classed  in  the  category  of  true  tumors. 

Kiesselbach's  Area. — In  1880  and  1884'^  Kiesselbach  had  drawn 
attention  to  the  clinical  experience  which  pointed  to  the  anterior 
portion  of  the  cartilaginous  nasal  septum  as  an  area  in  which  the 
bloodvessels  formed  a  plexus  from  which  hemorrhage  most  fre- 
quently occurred.  In  this  area  it  was  subsequently  shown  the 
vascular  neoplasms  were  most  apt  to  be  found,  and  in  1892  a  number 
of  articles  appeared  by  Schwager,  Alexander,  Scheier,  and  Heymann^ 
in  which  man}'  cases  were  reported,  and  since  which,  under  the 
name  of  bleeding  polypi  of  the  nasal  septum,  the  affection  has  been 
well  understood,  though  the  neoplasms  are  frequently  spoken 
of  as  angiomata.  Glas,^  in  1905,  included  them  in  an  extended 
account  of  the  angiomata  of  the  nose,  with  a  considerable  bibli- 
ography. He  drew  attention  to  the  fact  that  these  growths  develop 
usually  as  the  result  of  an  inflammation  of  the  mucosa  which  has 
resulted  in  an  atrophy  of  the  connective  tissue  and  that  they  are 
associated  with  a  disarrangement  of  the  elastic  elements  in  it. 
Torhorst,"  in  1906,  in  reporting  thirteen  cases  gave  an  exhaustive 
bibliography  of  the  subject  of  bleeding  polypi  of  the  septum.  Many 
reports  since  then  have  appeared  from  time  to  time,  but  nothing 
new  thus  far  appears  to  have  been  elicited. 

Nasal  Cysts. — The  subject  of  cysts  of  the  nasal  fossffi,  so  far  as 
they  have  an  especial  interest  in  the  history  of  rhinology,  presents 

1  Neumann:  Virchow's  Archiv  f.  path.  Anat.,  1861,  XXI,  p.  280. 

^  Virchow:  Die  Ivi-ankhaften  Geschwailste,  Berlin,  1863,  Band  3,  p.  306. 

^  Neumann:  1.  c. 

*  Mackenzie:  Diseases  of  the  Throat  and  Nose,  1884,  V.  2. 

^  Lange:  Wiener  medizinische  Presse,  1892,  No.  52,  XXXIII,  2071. 

'  Ricketts:  Cincinnati  Lancet  Chnic,  January  3,  1891,  n.  s.,  XXVI,  p.  1. 

'  Kiesselbach:  Berliner  klinische  Wochenschrift,  1884,  No.  24,  XXI,  p.  375. 

*  Archiv  flir  Laryngologie  und  Rhinologie,  1894,  I,  pp.  105,  265,  269,  273. 

*  Glas:  Archiv  fiir  Laryngologie  und  Rhinologie,  1905,  XVII,  p.  22. 

I'*  Torhorst:  Archiv  fur  Laryngologie  und  Rhinologie,  1906,  XVIII,  p.  268. 


25G       NASAL  ANATOMY,   PHYSIOLOGY,  AND  PATHOLOGY 

three  salient  points:  (1)  The  rehition  of  antral  cysts  to  the  question 
of  antral  hydrops;  (2)  the  origin  of  dentigerous  cysts;  (3)  bony  nasal 
cysts.  The  literature  of  these  points  will  be  largely  discussed  under 
the  head  of  the  Accessory  Sinuses.  It  may  be  added  that  in  1855 
Luschka^  in  the  course  of  an  article  on  the  mucous  polypi  of  the 
maxillary  antrum  gave  some  details  of  the  normal  histology  of 
the  antral  mucosa,  showing  that  in  places  glands  are  plentiful  in 
the  mucosa  and  that  small  cystic  dilatations  are  not  uncommon. 
Giraldes-  after  correcting  some  inaccuracies  of  Cruveilhier"*  in  the 
description  of  the  gross  anatomy  of  the  sinus  takes  up  the  subject 
of  the  histology  of  the  mucosa  and  the  formation  of  cysts  out  of 
the  dilated  ducts  and  acini  of  its  glands.  \'irchow'-  devotes  a 
page  or  two  to  a  mention  of  cystic  polypi  of  the  maxillary  antrum, 
which  sometimes  simulate,  or,  as  he,  supporting  Giraldes/  claimed, 
really  constitutes  the  condition  known  as  Hydrops  of  the  Antrum, 
and  while  there  has  l)een  considerable  dissenting  opinion,  Alexander,^ 
in  1897,  being  compelled  to  admit  the  possibility  of  a  serous  disease 
of  the  maxillary  antrum,  declared  there  is  good  reason  to  believe 
this  is  usually  the  origin  of  clear  fluid  in  the  cavity.  Dmochowski^ 
and  Xoltenius  (1.  c.)  have  taken  the  other  view  of  it. 

Osteomata. — The  other  neoplasms  that  occur  in  the  nose  scarcely 
need  mention  as  a  matter  of  rhinological  history.  Osteoma  perhaps 
may  be  referred  to  as  a  neoplasm  rather  more  frequent  in  the  nose 
than  in  other  regions  of  the  body.  Bornhaupt,"*  in  1881,  could 
collate  the  reports  of  about  49  cases.  Giintzer,^  in  1910,  reviewed 
the  literature  in  reporting  a  case  thirty  years  later.  The  mono- 
graphs dealing  with  the  neoplasms  of  a  benign  nature  in  the  nose, 
which  discuss  the  subject  most  exhaustively,  are  those  of  Hasslauer 
and  Ileymann.  In  1900  Hasslauer^"  wrote  an  essay  on  the  benign 
tumors  of  the  nasal  septum  with  a  bibliography  of  the  previous 
literature.  He  divided  them  into  oedematous  polypi  and  polypoid 
hypertrophy,  warty  growths  or  papillomata,  dividing  the  latter 
into  hard  and  soft,  the  bleeding  septal  polyp,  a  term  suggested  by 
Schadwaldt,  true  fibromata,  a  very  rare  form  of  growth,  adenoma 
in  its  benign  form  scarcely  less  rare,  myxoma,  cysts,  enchondroma, 
tuberculoma,  and  syphiloma.     Heymann,"  however,  has  given  the 

»  Luschka;  Virchow's  Archiv  f.  patli.  Anat.,  1855,  VIII,  p.  419. 
2  Girald(^s:  Virchow's  Archiv  f.  jjath.  Anat.,  1856,  IX,  p.  463. 
'  Cruveilhier:  Traite  d'anatomie,  Tome  IV,  M  ed.,  1852,  p.  55. 

*  Virchow:  Die  krankhaften  Gcschwiilsto,  Berlin,  1863,  Vol.  I,  p.  244. 

*  Giraldes:  1.  c. 

6  Alexander:  .Vrchiv  fur  Laryngologic  und  lihiuulogie,  1897,  VI,  p.  130. 

'  Dmochowski:  Centralblatt  fur  Allegemeine  Pathologic,  etc.,  March  14,  1895, 

VI,  p.  177. 

8  Bornhaupt:  Archiv  fur  klinische  Chirurgie,  1881,  XXVI,  p.  589, 

»  Guntzer:  iMedical  Record,  July  2,  1910,  LXXVIII,  p.  12. 

1°  Hasslauer:  Archiv  fiir  Laryngologic  und  Khinologie,  1900,  X,  p.  60. 

"  Heymann:  liandbuch  der  Laryngologic  und  Khinologie,  1900,  Band  III, 
p.  783. 


PROTOZOAL  GRANULOMATA   IN  THE  NOSE  257 

most  admirable  account  of  benign  nasal  neoplasms  in  general, 
with  an  exhaustive  bibliography  carried  up  to  1900.  Some  aspects 
of  the  granulomata,  tuberculous  and  syphilitic,  have  some  special 
interest  in  rhinology. 

Tuberculoma. — According  to  Chiari,^  who  himself  wrote  on  the 
subject  in  1893,  Riedel,-  in  1878,  and  Tornwaldt/  in  1880,  were  the 
first  to  describe  tuberculoma  of  the  nasal  mucosa.  Manasse,^  in 
1897,  drew  attention  to  the  difficulty  in  making  the  histological 
differentiation  between  syphilitic  and  tuberculous  granulomata 
in  the  nose,  owing  to  the  presence  of  giant  cells  and  coagulation 
necrosis  in  syphilomata,  especially  of  the  former,  indistinguishable 
from  those  of  tubercle.  There  have  been  a  large  number  of  reports, 
since  then,  of  primary  nasal  tuberculosis,  so-called,  and  of  nasal 
tuberculoma.  Those  of  Sachs,-^  Zarniko,*^  Rossi-Marcelli,^  Fein,*^ 
Oppenheimer,^  ]\Ioller,i"  Rosenbach^^  may  be  referred  to,  but  the 
contributions  of  Caboche,i-  who  discussed  it  as  a  larval  affection 
and  in  its  relation  to  ozsena,  and  that  of  Chavanne,^^  who  sub- 
divided it  into  the  acute  form  seen  in  miliary  tuberculosis  and  into 
the  chronic  form  including  tuberculoma  and  lupus,  are  the  most 
complete  and  exhaustive  monographs  on  the  subject. 

Nasal  Syphilis. — Extragenital  chancres  occur  on  all  the  accessible 
mucous  surfaces  and  in  some  regions  where  it  would  seem  impossible 
that  the  affection  could  be  carried.  As  to  the  nose,  a  list  of  the 
reports  of  such  cases  may  be  found  in  Schech's^''  article  on  the 
subject  in  1900  and  a  large  number  of  reports  have  appeared  since 
then,  as  mav  be  seen  from  Semon's  Centralblatt.  Secondarv  and 
tertiary  forms  of  syphilis  in  the  nose  have  not  formed  important 
topics  of  discussion  in  rhinological  literature. 

Protozoal  Granulomata  in  the  Nose. — These  are  the  rarest  of  all 
affections   if  we  are  to  judge   from   the  literature.     Blanchard^^ 

^  Chiari:    Archiv  flir  Laryngolo?;ie  imrl  Rhinologie,  1894,  I,  p.  121. 

-  Riedel:  Deutsche  Zeitschrift  fiir  Chirurgie,  1878,  X,  p.  .56. 

•'  Tornwaldt:  Deutsches  Archiv  fiir  khnische  Medizin,  1880,  XXVII,  p.  586. 

*  Manasse:  Virchow's  Archiv  f.  path.  Anat.,  1897,  Band  147,  p.  23. 

»  Sachs:  Mlinchener  medizinische  Wochenschrift,  1897,  No.  38,  XLIV,  p. 
1039. 

^  Zarniko:  Deutsche  medizinische  Wochenschrift,  1897,  XXIII,  Vereinsbei- 
lage.  No.  28,  p.  205. 

'  Rossi-Marcelh:  Archivii  Itahani  di  Laringologia,  1906,  XXVI,  p.  107. 

«  Fein:  Berhner  khnische  Wochenschrift,  1908,  No.  48,  XLIII,  p.  1.543. 

8  Oppenheimer:  New  York  Medical  Journal,  June  11,  1910,  XCI,  p.  1218. 

'°  Aloller:  Internationales  Centralblatt  fiir  Laryngologie  und  Rhinologie, 
1911,  XXVII,  194. 

'1  Ro.senbach:  Archiv  fiir  Laryngologie  und  Rhinologie,  1911,  XXIV,  231. 

'2  Caboche:  Annales  des  maladies  de  Torcille,  du  larynx,  etc.,  October,  1907, 
No.  10,  XXX,  pt.  2,  p.  260. 

"  Chavanne:  Annales  des  maladies  de  I'oreille,  du  larynx,  etc.,  August,  1909, 
No.  8,  XXXV,  pt.  2,  p.  240. 

"  Schech:  Heymann's  Handbuch,  1900,  Band  III,  p.  931. 

'5  Blanchard:  Bull,  de  I'Acad.  de  Med.,  November  13,  1900,  3  Serie,  XLIV, 
p.  504. 

17 


258     NASAL  ANATOMY,   PHYSIOLOGY,  AND  PATHOLOGY 

presented  two  cases  of  nasal  ijolypi  for  Dr.  Seeber,  of  the  University 
of  Buenos  Ayres,  who  chiinied  certain  cases  of  nasal  i)olypi  were 
caused  by  a  sporozoon,  ditl'ering  from  the  coccidia  which  develop 
in  the  connective  tissue,  in  WHVA  O'Kinealy'  described  a  papillo- 
matous mass  in  the  nasal  fossa  of  a  case  in  India  which  contained 
organisms  subsequently  classifi<'d  among  the  sjxjro/.oa  and  given 
the  name  of  Rhinosporidium  Kiucalyi.  A  few  other  cases  reported 
from  India  furnished  material  for  the  studv  of  the  organisms  bv 
Minchin  and  Fantham-  and  i)y  Bcattie.''  Wright^  described,  in 
1007,  a  similar  case  occurring  in  America. 

Malignant  Nasal  Neoplasms. — "^I'ln's  section  on  malignant  nasal 
neoplasms  woukl  be  a  long  one  were  I  to  refer  even  to  a  moiety 
of  the  important  works  on  the  subject.  Bosworth,*  in  1889,  gave  a 
resume  of  41  cases  of  sarcoma  of  the  nasal  passages  previously 
reported  in  literature,  while  in  I !»()()  Kiimmel"  found  90  references 
to  the  subject  in  forty  years.  \Miile  the  number  of  cases  of  malig- 
nant epithelial  growths  is  markedly  less,  the  latter  author  refers 
to  an  equal  number  of  reports,  (nirlt'  pointed  out  that  of  all 
cases  of  sarcoma  2  ])er  cent,  occur  in  the  nose,  of  carcinoma  0.04 
per  cent.,  /.  e.,  sarcoma  is  fifty  times  more  often  seen  in  the  nose 
than  carcinoma.  Other  exhaustive  monograi)hs  on  the  subject  may- 
be mentioned:  Gouguenheim  and  Ilelary,^  in  ]89."^,  on  malignant 
tumors  of  the  nasal  septum;  Dreyfuss-'  on  nasal  epitheliomata. 
He  referred  to  reports  of  12  cases  in  addition  to  his  own.  Finder,"^ 
in  1896,  wrote  on  malignant  growths  in  the  nose;  Cordes,'i  in  1903,  on 
adenocarcinoma  of  the  nose;  Donogjiny  and  Lenart,'-  in  1904,  on  the 
primary  carcinoma  of  Krompechcr  in  the  nose;  Althoff,!^  on  endo- 
thelioma of  the  nose  in  1907.  ]\lany  cases  of  malignant  disease  of 
the  nose  reported  in  the  first  decade  of  the  twentieth  century,  like 
malignant  disease  of  other  organs,  were  classified  as  endothelio- 
mata.  P^ven  at  present  the  distinction  between  certain  forms  of  car- 
cinoma and  certain  forms  of  sarcoma  is  so  uncertain,  as  outlined  by 

'  O'Kinealy:  Journal  of  Larj^ngolosy,  1903,  XVllI,  p.  ,'^75. 

-  Minchin  and  Fantham:  Quarterly  .Jouinal  of  Microscopical  Science,  1905, 
XLIX,  p.  521. 

•'  Heatfic:  Journal  of  TatlioloKV  and  Hactcriolo^^v,  1906,  XI,  p.  270. 

^  Wright:  Now  York  Alcdicarjouinai,  Decenibor  21,  1907,  Vol.  86,  p.  1149. 

*  Bosworth:  Di.seases  of  the  No.so  and  Nasojjharvnx,  1SS9,  p.  437. 

8  Kummel:  Hovmann's  Hanflhufh,  1900,  Band  111,  p.  874. 

'  Gurlt:  Archiv  fin-  klinisclie  Cliirurgic',  1880,  XXV,  p.  421. 

**  Gouguenheim  and  Helary:  Annales  des  maladies  de  I'oreille,  1893,  XIX, 
p.  295. 

"  Dreyfuss:  Archives  internationales  de  laryngologie  de  rhinologie  et  d'otol- 
ogie,  1892,  V,  p.  65;  Wiener  niedizini.sehe  Presse,  Nos.  36,  37,  38,  40,  1892, 
XXXIII,  1417,  et.  sexi. 

'"  P'inder:  Archiv  fiir  Laryngologic  und  IJhinolngie,  189(),  V,  p.  302. 

'iCordes:  Berliner  klini.sehe  Wdclieii.schrift,  February  2;>,  1903,  No.  8,  XL, 
p.   164. 

'-'  Donogany  and  Lenart:  Archiv  fiir  Laryngolgie  und  Rhinologie,  1904,  XV, 
p.  .586. 

'■^  AithofT:   Ihid.,  1907,  XIX,  p.  220. 


CHRONIC  INTRANASAL  DISEASE  AND  ITS  TREATMENT     259 

histologists,  that  much  confusion  in  cHnical  reports  has  resulted. 
Uffenorde/  in  1908,  gave  an  exhaustive  account  and  a  bibhography 
of  nasal  chondromata,  describing  also  operations  for  the  relief  of 
the  conditions.  The  rarer  forms  of  nasal  growths  observed  have 
been  a  cylindroma  by  Dembowski,^  in  1891,  a  lymphangioma  by 
Hamm,^  two  cases  of  congenital  glioma  by  Clark,^  in  1905,  a  case 
of  rhabdomyoma  by  Vail.-^  Serapin,*^  in  1903,  spoke  of  the  mixed 
tumors  of  the  palate,  and  numbers  of  cases  have  been  reported,  to 
some  of  which  Coflfin^  referred,  in  1909,  in  reporting  a  case,  which 
make  it  probable  that  such  growths  are  of  teratoid  nature. 


CHRONIC  INTRANASAL  DISEASE  AND  ITS  MODERN 

TREATMENT. 

Reflex  Neuroses. — The  evident  dependence  of  the  congestion 
of  the  erectile  mucosa  upon  reflex  action  connected  it  not  only 
with  the  neuroses  of  hay  fever  and  asthma,  but  with  the  histological 
changes  in  the  stroma.  A  perusal  of  the  subsequent  literature 
will  again  reveal  the  process  of  differentiation  in  nasal  affections, 
as  we  have  so  frec^uently  had  occasion  to  note  in  the  course  of  this 
history.  Schaeffer^  had  drawn  attention  to  local  disease  of  the 
upper  air  passages  as  an  exciting  cause  for  asthma  and  other 
neuroses,  but  it  was  not  until  the  publication  of  W.  Hack's^  paper 
on  "Reflex  Neuroses,"  in  1882,  that  the  attention  of  laryngologists 
was  arrested.  There  followed  a  large  number  of  contributions  to 
medical  literature  by  Elsberg,^"  John  X.  Mackenzie, ^^  Roe,  Daly, 
Bosworth,  and  many  others.  They  elaborated  this  chapter  in 
laryngology  to  an  extent  which  now  seems  overdrawn,  much  more 
prominence  being  given  to  local  conditions  than  to  the  underlying 
systemic  neurosis  in  the  etiology. 

Intranasal  Surgery. — This  immediately  stimulated  an  interest  in 
intranasal  surgery,  and  no  one  can  now  deny  that,  for  a  while, 
the  nose  was  a  much  abused  organ.     Chronic  hypertrophy  of  the 

1  I'ffenorde:  Archiv  fiir  Laryngologie  und  Rhinologie,  1908,  XX,  p.  255. 

2  Dembowski:  Deutsche  Zeitschrift  fiir  Chirurgie,  1891,  XXXII,  p.  385. 

5  Hamin:  Miinchener  medizinische  Wochenschrift,  February  24,  1903,  No.  8, 
L,  p.  ;^32. 

*  Clark:  American  Journal  of  the  Medical  Sciences,  May,  1905,  CXXIX,  p. 
769. 

*  Vail:  The  Laryngoscope,  December,  1908,  XVIII,  p.  933. 

^  Serapin:  Ref.;  Internat.  Centralblatt  fiir  Laryngologie  und  Rhinologie, 
1904,  XX,  p.  338. 

'  Coffin:  Annals  of  Otology,  Rhinology  and  Laryngology,  December,  1909, 
XVIII,  p.  788. 

*  Schaeffer:  Deutsche  medizinische  Wochenschrift,  Nos.  32,  33,  1879,  V,  pp. 
403,  418. 

"  Hack:  Berliner  klinische  Wochenschrift,  1882,  XIX,  p.  379. 

'0  Elsberg:  Trans.  Am.  Lar.  Ass'n,  1883,  p.  79. 

11  Mackenzie:  Am.  Jour.  Med.  Sc,  July,  1883,  Vol.  86,  p.  106. 


200      CIIROXIC  INTRANASAL  DISEASE  AND  ITS   TREATMENT 

mucosa  was  perhaps  the  l('^i()Il  wliicli  first  attracted  the  chief 
attention.  We  have  seen  that  the  treatment  of  nasal  obstruction, 
(hie  to  hy]i(Ttr()])hy  of  the  nnicosa,  l)y  means  of  nasal  bougies, 
had  been  reconnnended  by  Deschamj)  and  (lociuet  in  the  beginning 
of  the  century,  and  \ve  find  this  method  again  i)rop()sed  in  America 
at  the  beginning  of  the  development  of  modern  rhinology.^ 

Caustics  and  Cautery. — The  application  of  acids  which  we  have 
seen  in  the  records  of  ancient  medicine  was  one  of  the  sheet  anchors 
of  intranasal  therapy,  but  later  was  much  neglected.  Now  it  sprang 
suddenly  into  favor,  some  of  the  weaker  acids,  such  as  chromic  or 
chloracetic,  being  found  preferable  to  the  painful  action  of  the 
stronger  mineral  acids.  Soon,  however,  these  caustic  applications 
gave  place  in  a  large  extent  to  the  actual  cautery,  a  still  older  thera- 
peutic measure,  as  we  have  seen  in  the  Hippocratic  treatises;  but 
now  the  hot  metal,  by  means  of  the  electric  current,  brilliant  illumi- 
nation, and  cocaine,  had  become  much  more  manageable  in  its 
application.  The  introduction  of  this  method  of  cauterization 
goes  back  in  pre-laryngoscopic  times  to  the  work  of  ]\Iiddeldorpf, 
who  in  1854  published-  illustrations  of  a  cautery  armamentarium 
practically  the  same  as  that  used  for  many  years  in  rhinology, 
before  advantage  was  taken  of  the  electric  lighting  current,  now 
at  everyone's  service.  The  rheostat  has  almost  entirely  displaced 
the  "plunge  battery"  and  the  storage  battery.  A'oltolini,  in  1807, 
(1.  0.)  further  developed  the  technique  by  the  aid  of  laryngoscojjy. 
He  also  Avas  the  originator  at  this  time  of  electrolysis  in  various 
affections  of  the  nose  and  throat.  The  impro\ement  in  the  source 
of  the  electric  discharge  soon  brought  the  method  of  galvanic 
cauterization  into  universal  use.  An  ingenious  operation  frequently 
needs  only  the  recommendation  of  novelty,  and  ^Michael's  amusing 
little  poem  entitled  "Rhinologie,"  read  at  the  International  Con- 
gress of  1890,''  shows  that  even  by  that  time  intranasal  cauteriza- 
tion was  becoming  a  little  ridiculous.  For  almost  every  affection 
of  every  organ,  from  the  uterus  to  the  eyes,  after  the  s])read  of 
Hack's  ideas, 

"Dann  win!  (iic  Nasc  au.«Kc"hrann(, 
Denn  das  hilft  immer  wie  bekannt." 

The  Dental  Engine. — Other  methods  of  removing  intranasal 
obstruction  came  rai)idly  into  use.  The  dental  engine  seems  to 
have  been  first  used  by  Solis  Cohen.''  He  destroyed  an  exostosis  of 
the  nasal  passage  by  this  means  in  1878.  Seller  seems  to  have  been 

>  In  a  report  of  the  procrcdings  of  tlic  Now  York  Laryngological  Society 
we  find  Asch,  Wagner,  and  Smith  advising  the  use  of  intranasal  bougies  in 
hypertrophy  of  the  inferior  turbinated  bone.  N.  Y.  Med.  Jour.,  1874,  Vol. 
XIX,  p.  422. 

-  Die  Galvanocaustic,  von  Albrccht  Theodor  Middeldorpf,  1854. 

="  Vid.:  Internat.  C'ontralblatt  f.  Lar.,  1X!)(),  VJI,  p.  V.y.i. 

*  Cohen:  The  Medical  and  Surgical  Reporter,  July  13,  1878,  XXXIX,  p.  30. 


SEPTAL  OPERATIONS  261 

the  first  to  suggest  the  use  of  the  electromotor  for  driving  the 
dental  engine  in  this  operation.  ^  After  the  introduction  of  this 
adjuvant  the  apparatus  became  a  part  of  the  armament  a  riiun  of 
every  laryngologist,  at  least  in  America,  though  much  later  in 
Europe. 

Since  the  publication  of  the  first  edition  of  this  book,  the  use 
of  the  nasal  trephine  and  nasal  burrs  has  much  declined  and  has 
been  largely  superseded  by  other  methods  of  technique. 

Septal  Operations. — In  1887  Bosworth  reported  his  invention  of 
a  nasal  saw  for  septal  ecchondroses,-  and  this  method  of  their 
removal  was  so  practical  that  its  performance  immediately  became 
very  common,  but  this  also  since  the  advent  of  submucous  opera- 
tions has  Ijeen  largely  abandoned. 

It  is  an  entirely  arbitrary  procedure  to  begin  the  history  of 
operations  on  the  nasal  septum  with  the  operative  surgery  of 
Dieft'enbach.  \Ye  have  already  had  occasion  to  notice  the  antiquity 
of  operations  on  the  external  nose  for  the  purpose  of  restoring  its 
symmetry  destroyed  by  the  vengeful  ferocity  of  man.  The  tragic 
account  by  Dieft'enl)ach^  of  how  a  woman  revealed  to  him  in  the 
darkened  secrecv  of  her  home  a  face  mutilated  bv  disease,  a  horrible 
vision  that  made  her  an  outcast  on  earth  and  her  existence  a  torture 
to  herself,  is  one  of  the  passages  in  medical  literature  which  stand 
forth  with  a  dramatic  intensity  from  the  somnolent  and  dreary 
pages  it  falls  to  the  lot  of  the  medical  historian  to  read.  We  may 
use  this  lurid  gleam  of  human  suft'ering  as  the  point  of  departure 
for  us  in  an  account  of  operations  on  the  internal  frame-work  of 
the  nose  as  differentiated  from  those  plastic  procedures  so  skilfully 
practised  before  Hippocrates  by  the  Hindus.  With  the  possible 
exception  of  operation  on  the  accessory  sinuses  no  division  of  modern 
rhinology  has  exhibited  such  a  record  of  triumphant  achie\'ement 
as  has  attended  the  later  evolution  of  septal  operations.  Indeed, 
the  record  transcends  that  of  sinus  surgery  in  the  consideration 
that  few  or  no  victims  have  been  immolated  on  the  altar  of  man's 
presumption  in  venturing  where  angels  ought  to  fear  to  tread. 
As  a  matter  of  fact,  restoring  the  proper  aeration  and  drainage 
of  the  nasal  chambers  and  their  accessory  sinuses  has  acted  as  a 
preventive  of  those  conditions  which  have  formed,  too  frequently, 
excuses  for  rash  and  unbalanced  surgical  technicians  to  intrude 
where  common-sense  and  common  prudence  should  have  caused 
them  to  hold  their  hands. 

The  surgeons  in  the  early  part  of  the  last  century,  Langenbeck,^ 
Dieffenbach,   Chassaignac,'^  Gross,   and   other  writers  of  surgical 

1  Seller:  Diseases  of  the  Throat,  2d  Edit.,  Phil.,  1883,  p.  248. 

2  Bosworth:  Medical  Record,  January  29,  1887,  XXXI,  p.  115. 

'  Dieffenbach:  Die  op(n-ativ(>  C'hirurgie,  Leipzig,  1845,  Band  I,  p.  366. 
■*  Langenbeck:  Handbuch  der  Anatoniie,  Giittingen,  1843. 
5  Chassaignac:  Gazette  des  Hopitaux,  1851,  p.  419. 


262      CHRONIC  INTRANASAL  DISEASE  AND  ITS   TREATMENT 

text-books,  recommended  shaving  off  the  thi('keiiinj;.s  of  the  nasal 
septum.  Ileylen/  as  early  as  1847,  and  Duniarquay,-  in  1S59, 
seem  to  have  gained  access  to  the  internal  nose  by  an  external 
incision  and  thus  to  have  secured  room  for  a  submucous  excision 
of  i)ortions  of  the  cartilaginous  sei)tum.  As  early  as  1832  or  1833, 
I31andin,  and  in  1868,  lUiprecht,'*  used  a  punch  forceps  to  perforate 
the  cartilage  at  its  greatest  convexity. 

Etiology  of  Septal  Deviations. — Langenbeck,  in  1842,  is  said  to 
have  been  the  first  to  describe  septal  ecchondroses  and  exostoses 
as  crests  and  spurs.  Theile,*in  1855,  established  the  great  frequency 
of  deviations  by  the  examination  of  a  large  number  of  skulls,  report- 
ing that  out  of  117  he  found  only  29  symmetrical  se]:)ta,  the 
majority  being  deviated  to  the  left.  A  full  discussion  of  this 
matter  was  not  entered  into  until  much  later.  In  the  years  follow- 
ing 1880  descriptions  and  classifications  of  the  various  forms  of 
septal  deformity  were  made  by  Allen, ^  Zuckerkandl,  Schaus," 
Loewenberg,^  Ingals,*^  and  others.  Discussions  as  to  the  etiology 
included  the  consideration  as  factors,  lack  of  coordination  in  the 
development  of  the  septum  in  its  relation  to  the  cranial  bones 
first  suggested  by  Morgagni,  traumatisms,^  systemic  dyscrasias, 
local  inflammations, '0  racial  characters,  pressure  of  hypertrophied 
turbinates. '^  The  causes  of  deviated  septa  were  ascribed  to  rickets 
in  1883  by  Loewenberg,  and  in  rare  cases  to  cretinism  by  AUen'- 
in  1895.  In  the  discussion  on  Dr.  Delavan's  paper'^  at  the  meeting 
of  the  American  Laryngological  Association  in  1887,  John  X.  ]Mac- 
kenzie  drew  attention  to  the  rarity  of  deviation  of  the  septum  in  the 
negro  race.  Welcker,^*  in  1882,  stated  that  he  had  not  seen  deviation 
of  the  nasal  sej)tum  earlier  than  the  fourth  and  Zuckerkandl  not 
earlier  than  the  seventh  year.  In  1892,  in  a  number  of  memoirs, 
Potiquet^^  showed  the  relation  of  septal  deformity  to  the  mechanics 
of  the  development  in  adolescence  of  the  bones  of  the  face.  Indeed, 
Morgagni's  original  ideas  as  a  whole  have  prevailed  in  our  con- 

'  Heylen:  Annales  de  la  see.  de  med.  d'Anvers.,  Gaz.  Med.,  1847,  p.  810. 

2  Dumarquay:  Gazette  des  Hopitaux,  1859,  XXXII,  p.  470. 

^  Ruprecht:  Wiener  med.  Wochenschrift,  1868,  XVIII,  p.  1157. 

<  Theile:  Henle's  Zeitschrift  fiir  rationelle  Medizin,  1855,  n.  f.,  VI,  p.  242. 

*  Allen:  American  Journal  of  the  Medical  Sciences,  January,  1880,  LXXIX, 
p.    ()(). 

«  Schaus:  Archiv  fiir  klinischc  Chirursie,  1887,  XXV,  p.  147. 

"  Loewenberg;  Zeitschrift  fur  Ohrenheilkunde,  1883,  XIII,  p.  11. 

*  In{j;als:  Transactions  American  Laryngological  Ass'n,  1882,  p.  61. 

*  See  the  long  list  of  authors  regarding  traumatism.s  as  a  factor  in  the  etiology, 
in  Bosworth:  Treatise  on  Diseases  of  the  Nose  and  Throat,  N.  Y.,  1889,  Vol.  I, 
p.  287,  and  lioe:  Transactions  American  Laryngological  .Ass'n,   1896,  p.  203. 

'"  MacDonald:  Diseases  of  the  .N'ose,  2d  ed.,  London,  1892. 

"  Baumgarten:  Dcnitsche  medizinisclie  Wochenschrift,  1886,  XII,  p.  373. 

'^  Allen:  New  York  Medical  Journal,  1895,  LXI,  p.  139. 

"  Delavan:  Transactions  American  Laryngological  Ass'n,  1887,  p.  202,  et 
seq. 

'^  Welcker:  Die  Asymmetric  der  Nase  und  des  Nasenskelets,  1882. 

'5  Potiquct :  Bull,  et  Mem.  de  la  Societe  de  laryng.  de  Paris,  No.  7,  1892.  Med. 
moilernc,  Marcli  17-24,  1892,  III,  i)p.  I.")3,  169. 


ETIOLOGY  OF  SEPTAL  DEVIATIONS  263 

ception  of  the  causes  of  septal  distortion.  This  is  revealed  not 
only  in  these  later  works  but  in  the  earlier  ones  of  Theile  and 
Chassaignac.i  In  addition  to  those  already  referred  to,  ]Morell 
Mackenzie-  also  examined  many  hundreds  of  skulls  and  published, 
in  1884,  results  in  conformity  with  those  mentioned.  Trendelenburg, 
as  quoted  by  Schaus,^  first  drew  attention  to  the  coincidence  of 
high-arched  palates  and  deviated  septa,  a  question  much  discussed 
in  the  literature  as  to  the  etiology  of  ozpena  mentioned  elsewhere. 
Coincident  with  the  discussions  as  to  the  etiology  of  septal  irregu- 
larities arose  the  propositions  for  their  correction.  We  have  seen 
that  the  submucous  operation  for  the  removal  of  spurs  had  been 
conceived  and  executed  long  before.  Again,  in  1882,  submucous 
operations  for  the  removal  of  spurs  was  proposed  by  Ingals  (1.  c), 
who  used  a  nasal  saw  for  the  cartilage  after  raising  a  flap.  The 
latter  was  then  sutured  into  place  again.  ]\Iany  practised  this 
operation,  but  for  the  simple  removal  of  spurs  it  was  found  to  be 
cumbersome  and  troublesome,  out  of  proportion  to  the  result 
secured  in  comparison  with  the  simpler  operation  of  the  remo\al 
of  the  mucous  membrane  with  the  cartilage.  Ignoring  the  sugges- 
tion of  Quelmalz,  who  advised  the  patient  by  repeated  attempts 
each  day  to  try  to  bend  the  distorted  nose  into  symmetry,  Dieffen- 
bach,  Heylen,  Chassaignac,  Dumarquay,  in  the  first  half  of  the 
n  inteenth  century,  seem  to  have  made  the  first  serious  attempts  to 
straighten  the  septum  either  by  removing  portions  of  the  cartilage 
or  incising  it  as  a  submucous  procedure. 

Although  the  germ  of  the  submucous  operation  was  already 
existent  in  medical  publications,  efforts  to  straighten  the  deviated 
septum  followed  at  first  the  proposal  of  Adams,^  who,  in  1875. 
invented  a  forceps  for  its  forcilile  fracture,  after  which  it  was  to 
be  supported  by  splints.  Steele  and  Glasgow  put  cutting  blades  in 
Adams'  forceps  in  1881. '^  Roe,  who  also  in  many  publications 
described  many  other  ingenious  procetlures  to  correct  asymmetry 
of  the  nose,  subsequently''  greatly  elaborated  the  instruments  and 
the  methods  based  on  this  princple  while  the  operation  of  Asch," 
described  in  1890,  based  on  the  same  principles  was  widely  practised 
in  America  for  a  numlier  of  years  until  supplanted  by  the  modern 
submucous  operation.  I  need  only  mention  the  pin  operation 
advocated  by  Roberts,^  to  the  use  of  the  snare  by  Jarvis,^  and  of 

1  Chassaignac:   Bull,  dc  la  Soc.  do  Chir.,  1851-2,  II,  p.  253. 

2  Morell  Mackenzie:  Diseases  of  Throat  and  Nose,  Philadelphia,  1884,  II,  423. 

3  Schaus:  1.  c,  1887. 

^  Adams:  British  Medical  Journal,  October  2,  1875,  II,  p.  421. 

*  Steele:  St.  Louis  Courier  of  Medicine,  1879,  I,  p.  485.  Glasgow:  Trans. 
American  Laryngological  Ass'n,  1881,  p.  117. 

«  Roc:  Transactions  American  Lar^yngological  Ass'n,  1902,  p.  221. 

'  Asch:  Transactions  American  Laryngological  Ass'n,  1890,  p.  76. 

^  Roberts:  Practised  much  (>arlier,  though  published  in  1900;  Surgical  Treat- 
ment of  Disfigurements  and  Deformities  of  the  Face,  Philadelphia,  1900. 

'  Jarvis:  Transactions  American  Laryngological  Ass'n,  1882,  p.  69. 


204      CHRONIC  IXTRANASAL  DISEASE  AXD  ITS  TREATMENT 

trephines  and  ehisels  by  Seller,  in  1SS2,  to  the  disarticuhition  of 
tlie  sc])tuin  from  the  floor  of  the  nose  In'  Watson,'  in  189(). 

Submucous  Operation  for  Deviated  Septa. — In  IS-So  Burkhanlf- 
had  reeonnnended  lea\in<;-  the  niueous  niemlorane  on  both  sides 
of  the  septum  when  eartilaj^e  was  removed,  but  it  was  many  years 
after  this  before  the  teehnique  was  brought  to  its  present  perfection. 
As  we  have  seen  from  time  to  time,  submucous  extirpation  of  septal 
spurs  liad  been  performed  under  ureat  difhculty.  It  was  not  until 
the  use  of  cocaine  came  into  uiii\ersal  re(iuisition  that  it  could 
be  profitably  attempted,  and  not  until  after  the  introduction  of 
the  use  of  adrenalin  combined  with  it  that  there  was  opportunity 
for  the  successful  evolution  of  the  procedure.  Krieg's  first  publica- 
tion'^ in  1880  was  little  known,  but  in  1889  he  again  advised^  the 
resection  of  the  cartilage  with  its  mucous  coA'crings  on  the  convex 
side,  leaving  the  mucous  membrane  of  the  concave  side  to  regenerate 
fresh  cartilage.  He  refers  to  Hartmann  and  Petersen,  in  1882,  who 
had  resected  some  of  the  bent  cartilage  and  its  mucous  coverings 
and  then  reinserted  it  to  grow  in  its  old  place  in  better  position. 
Krieg  o})erated  successfully  l)y  his  method  on  2.'^  cases. 

Boenninghaus,^  in  1899,  improved  the  technique  of  Krieg.  This 
has  rendered  operation  for  straightening  the  nasal  septum  a  fully 
justifiable  one.  Before  Boenninghaus,  on  the  whole,  the  results 
obtained  scarcely  did  so  in  spite  of  the  many  devices  adopted. 
Both  Ilajek''  and  ^lenzeV  in  1904,  in  their  simultaneously  published 
articles,  improved  the  technique  of  Krieg  and  Boenninghaus  l)y 
leaving  the  mucosa  of  both  sides  of  the  septum,  but  Zarniko^ 
drew  attention  to  the  fact  that  G.  Killian^  had  recommended  it 
four  years  previously. 

In  America  Freer,'"  in  1903,  described  methods  for  the  submucous 
ablation  of  de\iated  and  thickened  parts  of  the  nasal  septum  and 
invented  for  the  puri)ose  a  large  luunber  of  knives,  forcej)s,  rongeurs, 
etc.,  of  special  pattern  which  have  been  extensively  used  in  America 
since  then.  Killian'^  further  elaborated  the  description  of  his 
method  of  operating  in  1904,  and  Freer  embodied  inucli  of  this  in 

'  Watson:  Transactions  American  Larynojologica]  As.s'n,  1896,  p.  218. 

^  Burkhai'dt :  Bericht  liber  die  cliirurKische  Abtheilung  der  Ludwigshospitals 
Charlotlenliiife  wiihrend  der  Jalire,  1SS5-S7. 

^  Krieg:  Medizinisclies  C'orresi:)ondenzblatt  des  Wiirttemberg:  aerztl.  Landes- 
vereins,  No.  2(),  ISSii,  LVl,  p.  201. 

■•  Krieg:  Berliner  klinische  Wochenschrift,  No.  31,  1889,  XX\'l,  j).  m9. 

^  Boenninghaus:  Archiv  fur  Laryngologie  und  l^hinologie,  1899,  IX,  p.  2()9. 

^  Hajck:  Archiv  fiir  Laryngologie  und  Rhinologie,  1903,  XV,  p.  45. 

'  Menzel:  Ibid.,  p.  48. 

"  Zarniko:  Archiv  fiir  Laryngologie  und  Ilhinologie,  1904,  XV,  \).  248. 

"  Killian:    ^'erhan(llungen    der    (Jesellsehaft    deutseher     Naturforscher    und 
Aerzte,  1899,   (1900),   11  Tli.,   II   Ilidfte,  p.  392.     IMiiller:  Archiv  fiir   Laryn- 
gologie und  Rhinologie,  1904,  X\',  p.  312.     Weil:  Ibid.,  p.  578,  also  wrote  on 
the  subject. 
10  Freer:  Journal  American  Medical  A.ss'n,  December  5,  1903,  XLI,  p.  1.391. 

"  Killian:  Archiv  fiir  Laryngologie  und  Rhinologie,  1904,  XVI,  362. 


COCAINE  265 

a  second  paper^  in  America  in  1905.  It  is  chiefly  to  Killian,  there- 
fore, we  are  indebted  if  not  for  the  conception  at  least  for  the 
thorough  elaboration  of  the  present  accepted  method  of  dealing 
with  deviations  and  spurs  of  the  nasal  septum. 

Nasal  Snares. — Spencer  Watson-  described  a  method  of  removing 
polypi  with  a  ring  knife.  Though  Jarvis'  snare  had  been  in  use  in 
this  country  several  years,  ]\Iorel-Lavalle^  made  use  of  an  external 
incision  in  the  removal  of  a  simple  polyp.  Others,  even  in  this 
country,  were  in  the  habit  of  using  caustics  and  even  the  sponge 
method  of  Hippocrates,  as  revived  by  Voltolini,  and  the  more  brutal, 
if  also  more  efficient,  method  of  evulsion  with  forceps,  galvano- 
caustic  snare,  etc. 

We  have  already  followed  the  history  of  the  nasal  snare  down 
to  the  nineteenth  century,  and  we  have  to  note  one  more  repro- 
duction and  modification  of  Hippocrates'  loop  before  we  reach 
the  Jarvis  Snare.  It  is  that  of  William  Robertson.*  He  used 
harpsichord  wire  which,  however,  did  not  run  through  a  cannula 
l)ut  through  lateral  guides  at  the  side  of  a  steel  post. 

Jarvis'  chief  improvement^  on  the  snare  of  Fallopius  consisted 
in  the  method  of  drawing  the  wire  through  the  cannula.  He  made 
use  of  an  outer  cannula  at  the  distal  end  for  the  attachment  of  the 
wire  and  the  adjustment  of  the  milled  nut  to  a  screw  thread  on 
the  inner  cannula,  by  the  use  of  which  the  loop  could  l)e  powerfully, 
accuratelv,  and  slowlv  tightened.  This  immediatelv  made  the 
nasal  snare  the  most  efficient  instrument  for  the  removal  of  soft 
intranasal  tissue,  and  the  numerous  subsequent  modifications 
testify  to  the  fact. 

Cocaine. — All  this  activity  and  zeal  for  the  removal  of  intransal 
tissue  would  have  been  very  much  less  had  it  not  been  for  the 
epoch-making  discovery  by  Carl  Koller,  in  1884,'^  of  the  surgical 
possibilities  of  cocaine.  The  three  greatest  events  in  the  history 
of  modern  laryngology  and  rhinology  are  the  demonstration  of 
the  utility  of  the  laryngoscope  by  Czermak  and  Tiirck,  the  obser- 
vation of  adenoids  by  Wilhelm  ]Meyer,  and  the  advent  of  cocaine. 
Its  use  in  laryngology  was  introduced  by  Jelinek."  The  impiuiity, 
so  far  as  pain  is  concerned,  with  which  the  mucous  membranes 
of  the  nose  and  throat  may  be  burned  and  lacerated  has  done 
perhaps  more  than  anything  else  toward  the  development  of  the 
technique  of  laryngology.     A  merciful  Creator  having  invented 

1  Freer:  Transactions  American  Laryngological  Ass'n,  1905,  p.  29. 

2  Watson:  Lancet,  February  23,  1884,  I,  p.  335. 

3  Morel-Lavalle:  Frogres  med.,  April  26,  1884,  XII,  p.  333. 
^  Robertson:  Edinburgh  Medical  Journal,  1805,  I,  p.  410. 

^  Trans.  Am.  Lar.  Ass'n,  18S0,  p.  130.  lie  appai'entlj'  was  unaware  of 
previous,  at  least  of  Fallopius'  invention. 

«  Wiener  med.  Woch.,  1884,  No.  43,  XXXIV,  p.  1276,  seq.  N.  Y.  Med. 
Journal,  Januar}^  3,  1885,  XLI,  p.  19. 

^  Wiener  med.  Woch.,  1884,  No.  45,  XXXI\',  p.  1332. 


266      CHRONIC  INTRANASAL  DISEASE  AND  ITS  TREATMENT 

pain  for  the  protection  of  the  tissues  of  the  animal  world,  its  aboli- 
tion by  the  inijenuity  of  man  has  been  necessarily  followed  by 
much  ruthless  and  unjustifiable  destruction  of  them,  but  never- 
theless among  flrugs  cocaine  ranks  only  second  to  the  general 
anaesthetics  in  the  mercies  vouchsafed  to  the  human  race. 

Adrenalin.— 1  n  1856  Vulpian^  had  noted  that  blood  from  the 
adrenalins  gave  a  specific  reaction  to  ferric  chloride  and  Arnold- 
tried  to  isolate  the  substance  ten  years  later.  Many  others''  did 
considerable  work  in  the  chemistry  of  the  substance,  but  it  remained 
for  Takamini''  and  Aldrich,'^  independently  of  one  another,  to  isolate 
it  in  a  chemically  pure  form  in  1901.  The  impure  extract  of  the 
suprarenal  capsules  had  long  been  known  to  have  an  effect  upon 
the  blood-pressure,  its  property  of  increasing  the  arterial  tension 
having  been  accepted  since  \'ulpian's  work.  The  work  of  Weiss 
and  Harris,*^  in  1004,  showed  that  this  is  due  to  or  at  least  associated 
with  contraction  of  the  perijiheral  arterioles.  W.  H.  Bates^  is 
said  to  have  been  the  first  to  use  an  aqueous  extract  of  the  supra- 
renal gland  on  the  conjunctiva  in  189(5.  Velich^  and  Konigstein^ 
published  articles  on  the  use  of  it  in  the  nose  and  throat  in  Menna 
in  1897,  while  the  paper  of  Swain,'"  in  1898,  introduced  it  in  America, 
though  he  seems  to  have  at  that  time  experimented  with  it,  not 
as  a  haemostatic  but  as  a  vasoconstrictor  when  locally  applied. 
Publications  in  large  numbers  rapidly  followed  and  the  preparation 
of  a  pure  extract  by  Takamini  and  Aldrich,  in  1901,  soon  made  it  a 
practicable  agent  for  use  in  keeping  the  field  clear  of  blood  in  intra- 
nasal operations.  As  an  adjuvant  to  cocaine  its  introduction  did 
more  than  any  other  two  things  to  advance  and  perfect  intranasal 
surgery. 

Thrombokinase  or  Thrombine. — Batelli,!'  in  1910,  devised  the 
practical  method  oi  sc])arating  thrombokinase,  the  ferment  body 
of  the  tissues  recognized  by  Morowitz  as  the  active  element  in  the 
causation  of  the  coagulation  of  the  blood.  This  method  was  prac- 
tised by  Strong,i2  jj^  191],  at  the  ^Manhattan  Eye,  Ear,  Xose,  and 
Throat  Hospital  in  New  York  and  the  resultant  product,  a  fine 
powder,  dusted  over  bleeding  surfaces  ])ronii)tly  checked  all  paren- 
chymatous oozing.     Unlike  adrenalin  it  has  no  reaction  of  vessel 

'  Vulpian:  Comptos  rendiis  soc.  biol.,  1856,  2  ser.,  Ill,  p.  223  . 

2  Arnold:  Virchow's  Archiv  f.  path.  Anat.,  1866,  XXXV,  p.  64. 

'  For  a  fuller  account  of  the  chemical  history   of   adrenalin   see   Hirsch : 
Handbuch  der  Biochemie,  etc.,  (Oppenheimer),  .Jena,  1910,  Band  .3,  h.  1,  p.  314. 

■•  Takamini:  American  .Journal  of  Pharmacy,  1901,  I^XXIII,  p.  .523. 

'  Aldrich:  American  .Journal  of  Physiology,  1901,  V,  457. 

«  Weiss  and  Harris:  Pfliiger's  ArchiV  f.  d.  ges.  Physiol.,  1904,  GUI,  p.  510. 

'  W.  H.  Bates:  New  York  iMedical  Journal,  May  16,  1896,  LXIII,  p.  647. 

*  Velich:  Wiener  medizinische  Blatter,  1897,  XX,  p.  735. 

'  Konig.stein:  Wiener  medizinische  I^resse,  1897,  XXXVIII,  p.  857. 
'"Swain:  Transactions  American  Larvngological  Association,  1898,  p.  165. 
»'  BateJli:  (;omi)les  rendus  de  la  soc.  iie  biologic,  1910,  LXVIII,  p.  789. 
•2  Strong:  New  York  Medical  Journal,  March  23,  1912,  XCV,  p.  591. 


THE  COMPRESSED-AIR  SPRAY  267 

relaxation,  and  it  can  be  used  on  surfaces  effectively  which  are 
already  bleeding. 

Inhalations  and  Detergents. — When  we  seek  the  origin  of  the 
local  topical  treatment  of  catarrh  of  the  upper  air  passages  by 
detergents  we  are  immediately  transported  far  back  into  the 
misty  records  of  Hindu  medicine,  and  the  same  may  be  said  of 
inhalations.  We  need  not  trace  these  through  the  intervening 
ages,  but,  after  the  incidental  references  which  have  found  their 
way  into  the  foregoing  pages,  1  am  sure  the  reader  will  not  regard 
the  taunt  of  the  Frenchman  altogether  without  its  sting:  "Tout 
ce  que  les  medicins  moderns  out  fait  pour  guerir  le  rhume  de  cerveau, 
(^'a  ete,  de  I'appeler  Coryza."  Had  he  been  familiar  with  medical 
history,  he  would  not  have  been  ready  to  concede  us  even  that 
meager  praise. 

The  compressed-air  spray  seems,  however,  to  have  really  been  an 
invention  of  a  comparatively  recent  date,  but  we  are  compelled  to 
seek  distant  fields  for  the  history  of  the  actual  inception  of  that 
idea.  Galen  is  said  to  have  prophesied  we  would  some  day  succeed 
in  isolating  the  pneuma  in  the  atmosphere  which  is  taken  into  the 
blood  in  respiration.  We  have  noted  the  observations  by  Lower  and 
Mayow  in  the  seventeenth  century.  Priestley,  in  actually  isolating 
oxygen  from  other  substances,  scarcely  knew  more  of  it,  still  term- 
ing it  dephlogisticated  air,  than  did  his  predecessors  in  the  seven- 
teenth century;^  but  the  time  was  ripe  for  its  elucidation,  which 
quickly  followed  under  the  admirable  and  accurate  experimentation 
of  Lavoisier.  He  was  the  first  to  give  it  the  name  of  Oxygen-  in 
1777.  This  very  soon  aroused  great  interest  in  the  gas  as  a  medicinal 
agent,  and  devices  were  adopted  for  its  inhalation  by  Beddoes  and 
Watt  in  1796.^  Some  years  before  this  John  ]\ludge,^  knowing 
nothing  of  the  pulmonary  residual  air,  nor  of  the  ciliated  epithelium, 
advised  the  inhalation  of  steam,  combined  with  opium,  with  the 
idea  that  the  medicament  would  thus  reach  the  ultimate  bronchioles. 
His  apparatus  was  very  much  like  the  present  croup  kettle  with  a 
flexible  tube.  AYhen  Davy  announced  the  existence  of  residual  air 
in  the  lungs  the  significance  of  it  was  immediately  appreciated 
by  ]\lagendie,  who  comprehended  the  impossibility  of  thus  applying 
medication  to  the  ultimate  ramifications  of  the  pulmonary  tree. 

The  Compressed-air  Spray. — The  idea  of  the  use  of  sprays  in  the 
air  passages  seems  to  have  originated  at  one  of  the  French  baths. 
Some  apparatus  for  spraying  the  body  had  been  in  existence  for 
some  years,  when  it  occurred  to  Dr.  Auphan,  in  1849,  to  utilize  it 

^  Priestley:  Experiments  and  Observations  on  Different  Kinds  of  Air,  London, 
1775. 

2  Comptes  Rendns  de  I'Academie  des  Sciences,  September  5,  1777. 

^  Considerations  on  tiie  Medicinal  Use  and  on  the  Production  of  Factitious 
Airs,  Bristol,  1796. 

*  A  Radical  and  Expeditious  Cure  for  a  Recent  Catarrhous  Cough,  4  ed., 
London,  1782. 


268      CHRONIC  INTRANASAL  DISEASE  AND  ITS  TREATMENT 

for  inhalation.  Sales-Girons  succeeded  in  inventing  a  portable 
apparatus  for  the  purpose.  It  was  a  very  awkward  affair,  some- 
wliat  on  the  principle  of  some  of  the  present  inhalation  glohes. 
A  fine  stream  was  broken  into  particles  by  being  thrown  with  force 
against  a  concave  surface.  Mathieu,  Bergson,  and  others  improved 
this  somewhat,  and  finally  the  latter  conceived  the  idea  of  breaking 
the  stream  of  water  into  a  spray  by  a  blast  of  air  or  steam  blown 
across  its  exit  from  a  narrow  tube.  This  of  course  necessitated  the 
emi)loyment  of  compressed  air.  This  ingenious  invention,  under 
various  names  and  modifications,  was  received  with  great  enthusi- 
asm by  the  budding  specialty  of  laryngology.  The  mucous  surfaces 
were  deluged  with  all  sorts  of  drugs  suspended  in  watery  and  oily 
media.  The  futility  of  much  of  this  sort  of  therapy  has  gradually 
become  apparent,  but  since  the  introduction  of  antiseptics  it 
has  found  its  place  in  laryngological  practice,  its  chief  \irtue 
consisting  in  impressing  the  patient  with  the  resources  and  skill 
of  his  doctor.  At  first  attempts  were  made  to  use  warm  sprays, 
but  as  early  as  18()1,  Dumarquay'  drew  attention  to  the  fact  that 
watery  sprays  have  a])])rj()ximately  the  same  temperature  after 
they  are  nebulized,  whatever  may  have  been  the  pre^•ious  tem- 
perature of  the  fluid.  I  find  the  use  of  nebulized  sprays  first 
recommended  in  America  by  Solis  Cohen  in  1800.- 

Improvements  in  Illumination. — Besides  the  great  strides  made  in 
operative  technique,  a  few  advances  have  been  made  in  the  art  of 
rliinoscopy  and  laryngoscopy  themselves.  Intensification  of  illumi- 
nation was  obtained  in  the  early  history  of  laryngoscopy  by  the 
use  of  the  oxyhydrogen  lime  light,  the  idea  beginning,  as  we  have 
seen,  with  Voltolini,  while  in  h'auvel's  book^  the  more  perfect 
apparatus  of  Drummond  was  recommended  for  the  purpose. 
French  has  used  Aranzi's  idea,  a  ray  of  light  reinforced  by  a  water 
lens,  and  found  the  best  illumination  in  the  rays  of  the  sun  thus 
intensified.  His  application  of  the  arc  light  to  the  purpose  is  also 
very  efficient,  he  having  adopted  both  these  expedients  in  his 
photographs  of  the  larynx  and  nasopharynx.*  Tiirck'^  anrl  others 
had  attempted  to  magnify  the  laryngoscopic  image  by  means  of 
lenses  and  concave  mirrors,  and  Hirschberg,''  later,  attemjited  the 
same  thing.  These  attempts  have  proved  of  no  practical  value. 
By  means  of  stroboscopy,  Oertel,^  in  1878,  showed  the  wa\e  lines 
of  different  tones  in  the  vibrations  of  the  vocal  cords. 

1  Bullc'tin  de  rAcadcmie  Imperiale  de  Medecine,  1861-62,  XXVII,  p.  26.  A 
fuller  a(;c(junt  of  the  history  of  sprays  may  be  found  in  Lewin's  book,  Inhala- 
tions-Therapie,  to  which  I  am  indebted  for  some  of  the  above  information. 

2  Medical  Record,  1866-67,  I,  p.  147. 

^  Trait6  pratique  des  maladies  du  Larynx,  Paris,  1876. 

*  Vid.  Trans.  Am.  Lar.  Ass'n,  1882,  1883,  1886,  1888,  1896. 

6  Tiirck:  Zeitsch.  der  K.  K.  (W-soli.  der  Aerzte  zu  Wien,  1859,  No.  52,  p.  817. 

^  Hirschberg:  Virchow's  Archiv  f.  path.  Anat.,  1877,  LXIX,  p.  146. 

^  Oertel:  Centralblatt  f.  die  medicin.  Wissenschaft,  1878,  XVI,  p.  99. 


THE  ACCESSORY  NASAL  SINUSES  269 

THE  ACCESSORY  NASAL  SINUSES. ^ 

The  period  of  my  activities  in  laryngology,  covering  as  it  does 
more  than  twenty -five  years,  includes  in  its  experiences  the  rise 
of  interest  in  and  the  eager  cultivation  of  our  modern  knowledge 
of  diseases  of  the  accessory  sinuses  of  the  nose.  It  witnessed  the 
absurd  exaggerations  of  notions  as  to  the  frequency  with  which 
sinus  disease  requires  surgical  intervention,  and  the  rash  resort  to 
devastating  destruction  of  nasal  structure  in  operative  measures 
designed  to  afforrl  relief  to  affections  more  or  less  trifling  in  them- 
selves. It  experienced  the  disasters,  "the  doctor's  mistakes  which 
the  earth  covers,"  the  disappointments  of  too  enthusiastic  operators 
and  too  credulous  patients.  It  saw  reputations,  world-wide  in  the 
narrow  domain  of  our  specialty  made  out  of  a  manual  dexterity  per- 
haps, but  also  out  of  an  intrepidity  of  spirit  which  often  encroached 
too  much  upon  the  rights  of  humanity  and  too  often  disregarded 
the  precepts  of  conscientious  professional  conduct.  It  saw  on  the 
other  hand  the  unselfish  pursuit  of  knowledge,  the  single-minded 
endeavor  to  spread  its  beneficent  influence  and  make  it  a  heritage 
of  future  medical  men.  A  period  of  twenty-fi\e  years  has  seen  this 
slow  and  modest  toil  rewarded  by  the  fruition  of  a  more  rational 
way  of  looking  on  sinus  disease  as  usually  a  minor  evil  with  which 
the  system  is  often  able  to  cope  imaided  or  assisted  only  by  moderate 
and  comparatively  harmless  intervention.  It  has  seen  efl'ective 
relief  rendered  in  those  dangerous  cases  of  suppurative  and  neo- 
plastic disease  which  pursued  their  course  unchecked  to  a  fatal 
issue  a  generation  ago. 

There  is  doubtless  still  much  to  be  learned,  many  improvements 
still  to  make,  much  enlightenment  still  to  be  gained  in  the  study 
of  sinus  disease,  but  it  is  safe  to  say  that  the  prefatory  stage  to  the 
sober  scientific  investigation  of  it  has  passed  by. 

There  can  be  no  doubt  that  the  material  causes  of  the  activities 
in  this  field  of  medical  science  had  their  foundations  in  that  develop- 
ment of  mechanical  and  technical  art  which  produced  the  laryn- 
goscope and  the  illumination  of  hidden  recesses  of  the  body  by 
means  of  intensified  gas  light,  electric  incandescence,  and  the 
mysterious  powers  of  the  actinic  rays  produced  by  atomic  disin- 
tegration. Still  more  far  reaching  in  its  effects  was  the  intellectual 
expansion  which  resulted  in  the  extension  of  anatomical  study,  both 
gross  and  microscopic,  to  the  bony  tissues  and  their  softer  linings 
in  the  nose  and  the  adnexa. 

It  is  unsafe  to  prophesy,  but  it  seems  very  probable  that  further 
advance  is  to  be  made  in  the  future  along  physiological  lines  which 
must  include  investigations  in  the  microbiology  and  the  metabolism 
of  the  nasal  mucosa  and  its  ramifications  in  the  sinuses,  and  to  this 

^Reprinted  without  alteration  from  Tlic  Laryngoscope,  February,  1913. 


270  THE  ACCESSORY  NASAL  SINUSES 

there  must  be  allied  the  consideration  of  the  relationshij)  which 
this  special  microbiology  and  special  metabolism  bears  to  like 
phenomena  in  the  general  system. 

We  have  seen  how  completely  and  exhaustively  the  subject  of 
the  surgical  treatment  of  the  Antrum  of  Ilighmore  has  been  dealt 
with  in  literature,  largely  before  the  nineteenth  century. 

Beginnings  of  Interest  in  Sinus  Disease. — After  the  beginning  of 
the  devcloj)ment  of  Modern  Iihinology  in  the  early  eighties,  interest 
was  gradually  aroused  in  the  subject  of  accessory  sinus  disease. 
In  the  discussion  at  the  meeting  of  the  German  Naturalists  in  bSSC), 
the  idea,  traces  of  which  we  have  seen  in  earlier  literature,  again 
arose  as  to  the  connection  l)etween  sinus  disease  and  oza^natous 
atrophic  rhinitis.  The  etiology  of  maxillary  sinus  disease  in  the 
vast  majority  of  the  cases  was  at  this  time  ascribed  to  carious  teeth. 
Among  those  who  accepted  this  view  were  Killian,^  Schmiegelow,- 
and  MacBride.^ 

Mikulicz^  brought  into  vogue  his  operation  of  perforating  the 
maxillary  sinus  with  a  trocar  and  cannula  from  the  nasal  chambers, 
but  the  perforation  through  the  alveolus  still  remained  the  more 
common  procedure  as  long  as  the  teeth  were  accepted  as  the  chief 
factors  in  the  etiology  of  suppuration. 

Interest  was  soon  aroused  in  America,  and  Dr.  J.  H.  Bryan  in 
1889  read  a  paper  before  the  American  Medical  Association  on 
the  subject.  Considerable  had  been  said  as  to  the  difficulty  in 
diagnosticating  the  presence  of  pus  in  the  maxillary  sinus,  and  the 
trocar  of  Krause  was  devised  for  exploratory  puncture,  irrigation, 
and  the  insufflation  of  iodoform  and  other  powders,^ 

Transillumination. — Another  method  of  diagnosis  attracted  much 
more  attention.  Dr.  Theodor  Ileryng,'^  in  1889,  urged  the  idea  of 
\  oltolini,  the  electric  transillumination  of  the  antrum.  MacBride 
and  Vohsen  both  read  papers  on  this  subject  at  the  International 
Congress  in  1889.  Even  as  early  as  this,  in  the  discussion  of 
Vohsen's  paper,  Freudenthal  and  Heymann  pointed  out  that 
transillumination  is  not  by  any  means  a  reliable  method  by  itself 
for  diagnosis  of  sinus  disease,  and  in  spite  of  the  considerable  vogue 
the  procedure  has  had  in  rhinology,  this  remains,  twenty-five  years 
later,  the  prevailing  sentiment. 

Latent  Suppuration. — Lichtwitz^  and  Jeanty^  described  cases  of 
latent  suppuration  of  the  Antrum  of  Highmore,  pointing  out  that 

'  Killian:]\IonatssclH-if1  [.Ohrpnlicilkundc,  otc,  1SS7, 10,  11,  XXI,  i)p. 276,321. 
^  Schmiegelow:  Ho.spitals  Tidcnde,  LS.SS,  'A  R.,  VI,  i)iv  49,  S3,  133,  198. 
»  MacBride:  Edin.  Med.  Jour.,  April,  18S8,  XXXIII,  p.  SS7. 

*  Mikulicz;  Archiv  f.  klin.  Chirurg.,  3  Heft.,  1887,  XXXIV,  p.  626. 

*  Moritz  Schmidt:  Berliner  klinische  Wochenschrift,  1888,  No.  50,  XXV,  p. 
1012.  Friedlander:  Berliner  klinische  Wochenschrift.  1889,  No.  37,  XXVI, 
p.  815. 

«  Heryng:  Berliner  klinische  Wochenschrift,  1889,  No.  35,  XXVI,  p.  774. 
'Lichtwitz:  Priiger    niedizini.sche    Wochenschrift,    1892,    15,    16,    XVII,    p. 
155,  167. 
"  Jeanty:  De  Tempydme  latente,  etc.,  Bordeaux,  1891. 


FRONTAL  SINUS  271 

it  was  frequently  bilateral.  Writers  became  more  cautious  and 
critical  as  to  the  results  of  the  treatment  then  in  vogue,  chiefly 
drainage  through  an  alveolar  perforation.  ^Jany  cases  of  antrum 
disease  alone  failed  to  respond  to  this  treatment,  while  the  fact 
that  the  upper  row  of  sinuses  was  furnishing  the  pus  and  the  antrum 
was  but  a  reservoir,  for  it  was  still  unknown  or  unappreciated. 

Necrosing  Ethmoiditis. — As  to  the  ethmoid  cells,  in  18S7  Woakes^ 
drew  attention  to  a  cleavage  of  the  middle  turbinate  bone  which 
he  declared  to  be  due  to  necrosing  ethmoditis.  Although  it  has 
subsequently  been  shown  that  this  apparent  cleavage  of  the  bone 
is  often  really  a  presentation  of  a  polyp  from  beneath  it,  having  its 
attachment  to  the  hiatus  similunaris  or  its  neighborhood,  this 
work  of  Woakes  created  great  interest  in  the  pathological  states 
of  the  ethmoidal  labyrinth  and  led  to  the  liveliest  discussions  for 
several  years.  Bosworth,^  in  1891,  wrote  on  the  various  forms  of 
disease  of  the  ethmoid  cells.  Griinwald,^  in  1893,  published  his  well- 
known  brochure  on  nasal  suppurations,  special  attention  being 
drawn  to  the  affections  of  the  ethmoid  and  sphenoid  ca\ities. 
Although  there  were  a  number  of  other  articles  on  disease  of  the 
cavities  at  this  time,  these  three  contributions  to  the  subject  in 
England,  America,  and  Germany  formed  perhaps  the  greatest 
stimulus  to  the  flood  of  literature  of  the  subject  which  followed. 
Griinwald's  radical  views  as  to  occurrence,  complications,  and 
treatment,  Woakes'  exaggerated  views  as  to  the  connection  of 
ethmoditis  and  nasal  polypi,  and  the  still  more  exaggerated  views 
of  Bosworth  as  to  ethmoiditis  and  the  etiology  of  asthma  and  hay 
fever  furnished  themes  for  animated  attack  and  defence. 

Frontal  Sinus. — Schaeffer,^  in  1890,  had  proposed  to  drain  the 
frontal  sinus  by  enlarging  its  communication  through  the  infun- 
dibulum  with  the  middle  meatus.  In  1891  Baumgarten,'^  Montaz," 
Silcock,^  Griinwald,^  and  others  wrote  papers  on  frontal  sinus 
disease,  most  of  them  counseling  the  trephining  of  the  sinus  exter- 
nally. Among  the  ophthalmologists,  disease  of  the  frontal  sinuses 
and  ethmoidal  cells  had  for  a  long  time  been  known  as  the  origin 
of  orbital  abscess^  and  many  operations  were  performed  by  them 
in  which  these  cavities  were  reached  from  an  incision  at  the  inner 
and  upper  angle  of  the  orbit.     Brain  abscess  having  its  origin  in 

1  Woakes:  Nasal  Polypus,  Phil.,  1887. 

-  Bosworth:  New  York  Medical  Journal,  November  7,  1891,  LIV,  p.  505. 

^  Grunwald:  Die  Lehre  von  den  Naseneiterungen,  etc.,  Mi'mchen,  1893. 

^Schaeffer:  Deutsche  medizinische  Wochenschrift,  1890,  No.  41,  XVI,  p. 
905. 

*  Baumgarten :  Pester  medizinische  Chh-urgische  Prcsse,  1891,  10,  XXV'll, 
p.  226. 

^  Montaz:  Des  Sinus  frontaux  et  de  leur  trepanation,  1891. 

'  Silcock:  British  Monlical  .Journal,  April  25,  1891,  I,  p.  912. 

"Griinwald:  Miinchener  medizinische  Wochenschrift,  1891,  Nos.  40,  41, 
XXXyill,  p.  699,  721. 

®  Guillemain:  Etude  sur  les  absces  des  Sinus  frontaux,  1892. 


272  THE  ACCESSORY  NASAL  SINUSES 

suppuration  of  tlic  frontal  sinuses  was  noted  in  LSDl'.'  Lielitwitz,- 
in  \S\y.},  aii'ain  urffotl  tlie  ])racti('al)ility  of  roacliinu-  the  frontal  sinus 
through  the  nose  by  means  of  i)r()he  and  eannula.  For  years  this 
idea  was  discredited  as  dangerous  and  even .  impossible  in  the 
majority  of  cases  by  many  writers. 

Woakes  had  claimed  ethmoiditis  as  the  chief  factor  in  the 
etiology  of  nasal  polyjn,  and  (Jriinwald  had  traced  that  of  oza-na 
to  affections  of  the  accessory  sinuses,  an  idea  which  is  still  more  or 
less  prevalent  among  a  minority  of  rhinologists.  Among  others 
Chiari^  soon  oi)])()se(l  these  views,  referring  to  128  cases  of  atro])hic 
rhinitis  with  ozu'iia  without  sinus  disease  and  (il  cases  of  nasal 
polypi  without  caries  of  the  ethmoid  cells.  Thcs(>  matters,  as  many 
others  which  engaged  the  attention  of  clinical  obser\  ers  in  rhinology, 
could  not  be  intelligently  discussed  without  a  more  accurate  knowl- 
edge of  the  anatomical  relations  and  postmortem  conditions  of  the 
accessory  sinuses. 

Postmortem  Examinations. — In  1.S77  Schalle^  had  described  a 
method  of  examining  these  cavities  in  the  cadaver  without  dis- 
figuration. This  had  been  the  great  drawback  to  a  thorough  under- 
standing of  anatomical  and  pathological  points  of  interest  and 
importance,  and  consequently  a  decided  hindrance  to  clinical 
activity.  Since  1SS2  the  invaluable  work  of  Zuckerkandl,''  sub- 
sequently much  enlarged,  had  been  almost  the  sole  guide  of  surgical 
procedure  as  it  was  subsequently  the  inspiration  of  much  work  in 
the  anatomy  and  i)athology  of  these  regions.  In  1891  Harke,'' 
referring  to  the  work  of  Schalle,  introduced  an  improvement  in  the 
postmortem  technique  of  the  examination  of  the  nasal  chambers 
and  the  sinuses.  Subsequently,  in  1895-(),  Harke,'^  Dmochowski,^ 
and  E.  Fraenkel-'  ditl  a  great  deal  to  extend  our  knowledge  of  the 
anatomy,  pathology,  and  bacteriology  of  the  nasal  accessory  cavities. 

The  discovery  made  postmortem  that  such  a  large  proportion 
of  cases  show  eviflence  of  latent  disease  of  or  purulent  collections 
in  the  Antrum  of  Ilighmore  did  much  not  only  to  establish  this 
l)oint,  but  did  nnich  also  to  show  that  j^atients  may  carry  around 
with  them  for  years  foci  of  pus  in  the  ca\'ities  of  the  nose  without 
inconvenience  or  danger.  The  prevalence  of  epidemics  of  influenza 
throughout  the  civilized  world  during  the  period  of  growing  interest 

'  Bericht  des  AUgemeinen  Krankenhauses  in  Wi(>n  fiir  1S90.  Wiener  Medi- 
zini.sc'he  Blatter,  No.  VS,  1S92,  XV,  p.  200. 

-  Liclitwitz:  Annalcs  des  maladies  dc  I'oreille  du  nez,  etc.,  1893,  XIX,  p.  132. 
^  Chiari:  Wiener  kliiiische  Wochenschrift,  Xo.  14,  189-4,  VII,  p.  420. 
■•  Schalle:  Vircho\v'.s  Archiv  f.  path.  Anat.,  1877,  LXXI,  p.  200. 

*  Zuckerkandl:  Normale  und  pathologischc  Anatomie  der  Nasenhohle  und 
ihrer  pneumatischen  Anhange,  1882,  1892,  1893. 

«  Harke:  Virchow's  Arcliiv  f.  path.  Anal.,  1891,  CXXV,  p.  410. 
'  Harke:  Beitriige  zur  Pathologic  und  Therapie  der  oberen  Atmungswege, 
etc.,  Wiesbaden,  1895. 

*  Dmochowski :  Archiv  fiir  Laryngologies  und  Rhinologie,  etc.,  1895,  III, 
Heft  3,  p.  255. 

»  E.  Fraenkel:  Virchow's  Archiv,  1896,  Band  143,  p.  42. 


HISTOLOGY  273 

ill  these  conditions  stimnlated  the  study  of  them,  as  it  gave  rise 
to  the  opportunity  for  it.  It  was  early  recognized  that  this  affection 
was  the  cause  of  the  occurrence  of  many  acute  attacks  and  that 
these  became  the  starting-points  of  much  subsequent  chronic 
disease.  While  these  opportunities  for  clinical  study  doubtless 
bore  an  important  part  in  the  causes  which  underlay  the  study  of 
sinus  disease  it  could  not  have  been  carried  to  the  fruition  of  the 
present-day  status  of  our  knowledge  but  for  the  continuation  of  the 
pursuit  of  the  fundamental  embryological,  anatomical,  and  patho- 
logical facts  brought  out  in  the  works  of  Sieur  and  Jacobs,  Killian, 
Onodi,  and  others. 

Bacteriology. — Von  Besser,^  in  1889,  had  shown  the  presence  of 
pyogenic  organisms  in  the  normal  maxillary  antrum.  Dmochowski, 
in  1895,  showed  that  in  nearly  20  per  cent,  of  postmortem  exami- 
nations of  cases  dead  of  various  diseases  there  was  a  pathological 
state  of  the  mucosa  of  the  maxillary  antrum.  Like  results  were 
also  obtained  by  Eugen  Fraenkel  in  postmortem  examinations 
of  a  large  number  of  cases  about  the  same  time.  For  many  years 
these  were  the  only  in\estigations  of  importance  wdiich  were 
published  on  the  flora  of  the  accessory  sinuses.  In  1910  Turner 
and  Lewis-  published  important  papers  on  their  bacteriology  in 
which  they  showed  the  dominant  organisms  were  not  constant, 
but  that  pneumococci,  streptococci,  staphylococci,  bacteria^  coli, 
diphtheria^,  influenzae  were  all  found  in  various  cases.  They 
emphasized  a  point,  which  had  been  occasionally  mentioned  by 
others,  that  when  the  purulent  matter  contained  a  large  number 
of  lymphocytes,  and  when  the  pre^•ailing  organism  is  a  strepto- 
coccus, the  chronic  cases  are  apt  to  be  rebellious  to  treatment 
and  simple,  douching  does  not  suffice.  When  these  conditions  do 
not  prevail  simple  douching  was  often  sufficient.  They  placed 
the  figure  of  proportionate  frequency  of  the  dental  factor  in  maxil- 
lary sinus  suppuration  at  one-third  of  the  cases.  Sobernheim,^  in 
1910,  also  made  observations  on  the  bacterial  flora  in  chronic 
empyema  of  the  maxillary  sinus  in  which  he  came  to  somewhat 
analogous  conclusions  as  did  Turner,  but  found  in  some  cases  that 
the  pus  was  sterile — in  seven  out  of  the  twenty-five  cases  examined. 
This  certainly  is  a  surprisingly  large  number  of  negative  results, 
and  conclusions  from  it  must  be  accepted  with  caution. 

Histology. — Weichselbaum  and  Zuckerkandl,  especially  Zucker- 
kandl,  in  his  later  editions  (189-')),  had  made  a  special  study  of  the 
minute  anatomy  of  the  mucosa  of  the  accessory  sinuses.  Wingra\e^ 
showed  sections  of  granulation  tissue  from  the  frontal  sinus  in 

^  Von  Bcsser:  Beitriige  zur  jiathologischcii  .\natomie,  1889,  VI,  p.  333.        ^ 

^  Turner  and  Lewis:  Edinburgh  Medical  Journal,  Aj)ril,  1910,  n.  s.,  IV,  p. 
293.    Lewis:  Journal  of  Patlu)logy  and  Bacteriologj',  July,  1911,  XVI,  p.  29. 

^  Sobernheim:  Archiv  fiir  Laryngologie  und  Rhinologie,  etc.,  1910,  Heft  2, 
XXIII,  1).  1.59. 

"  Wingrave:  British  Med.  Jour.,  1898,  I,  p.  1268. 

18 


274  THE  ACCESSORY  NASAL  SINUSES 

1898.     Andre'  had,  in  1905,  written  a  thesis  on  the  lymphatics  of 
the  nose,  including  reference  to  those  of  the  accessory  cavities, 
Griinwald,-  in  1910,  referrhig  to  Andre's  work,  supplemented  it,  and 
his  observations  go  to  contradict  the  conclusion  that  the  lymphatic 
vessels  of  the  sinuses  communicate  through  the  bony  walls  with 
those  of  the  nasal  chaml)er.     On  the  contrary  they  seem  only  to 
follow  the  mucous  membrane  itself.     It  may  be  remarked   that 
familiarity  with  the  histology  of  the  mucosa  and  an  ai)])reciation 
of  the  limitations  of  the  injection  technique,  on  which  this  opinion 
is  based,  mav  well  lead  us  to  doubt  that  in  life  infection  is  onlv 
thus  carried  by  the  lymph  channels.    There  are  many  of  them  so 
very  minute  that  they  may  well  give  passage  of  bacteria  and  not 
to  injected  material.     However,  the  channels  of  infection  along 
which  the  germs  spread  to  new  localities  are  still  moot  points  in 
every  region  of  the  body.     It  seems  very  probable  that  even  the 
nearby  spread  of  infection  takes  place  in  the  blood  current  rather 
than  by  the  lymph  spaces.    The  work  of  Oppikofer''  deserves  notice 
for   its   extended   investigation   of   the   normal   and   pathological 
anatomical  conditions  of  the  sinuses,  especially  of  their  histological 
anatomy.    It  signalizes  one  of  the  forward  steps  taken  in  the  more 
thorough  attempts  to  study  the  actual  processes  of  disease  as  revealed 
by  the  microscope,  but  it  also  deals  with  facts  in  the  gross  antomy 
of  the  parts.     Eschweiler*  contributed  to  the  histology   of  the 
mucous  membrane  of   the   frontal   sinuses,  and   Oppikofer^   sub- 
sequently' extended  his  work.     Goetjes,*^  in  1909,  devoted  an  essay 
solely  to  the  pathological  anatomy  and  histology  of  the  sphenoidal 
sinus,  having  examined  it  in  31  cases  postmortem.    Like  previous 
observers,  he  concluded  that  pathological  changes  observed  post- 
mortem were,  as  a  rule,  acute  conditions  arising  during  the  later 
stages  of  the  affections  of  which  the  patients  died.     They  often 
contained  stomach  contents.    He  did  not  agree  with  the  statement 
of  some  of  the  previous  observers,  who  claimed  that  in  the  majority 
of  the  cases  there  had  been  an  antecedent  rhinitis,  and  there  is 
some  reason  to  believe  that  this  is  at  least  less  frequently  the 
case  than  in  inflammatory  affections  of  the  other  sinuses. 

Cysts. — Turner,^  in  1903,  made  a  valuable  contribution  to  the 
pathology  of  bone  cysts  in  the  accessory  sinuses  of  the  nose, 
especially  with  regard  to  those  of  the  maxillary  sinus  developed 

^  Andr^ :  Contribution  a  I'^tude  des  lymphatiques  du  nez  et  des  fosses  nasales, 
These  de  Paris,  1905. 

2  Griinwald:  Archiv  fiir  Laryngologie  und  Rhinologie,  etc.,  1910,  Heft  1, 
XXIII,  p.  1. 

^  (3ppikofcr:  Archiv  fiir  Laryngologie  und  Rhinologie,  etc.,  1906,  XIX,  p.  28. 

*  Eschwciler:  Archiv  fiir  Larj^ngologic;  und  Rhinologie,  190.5,  XVII,  p.  437. 

*  Oppikofer:  ^Vi-chiv  fiir  Laryngologie  und  Rhinologie,  1909,  XXI,  h.  3,  p. 
422. 

^  Goetjes:  Archiv  fiir  Larvngologie  und  Rhinologie,  1909,  XXII,  p.  129. 
'  Turner:  Edinburgh  Medical  .Journal,   1903,  n.  s.,  XIV,  pp.  299,  405,  511. 
The  Laryngoscope,  November,  1904,  XIV,  p.  817. 


CYSTS  275 

from  the  dental  embryogenetic  foci.  As  to  the  cysts  of  the  ethmoid 
Onodi^  was  warranted  in  saying  that  they  are  anomahes  in  the 
development  of  the  ethmoidal  labyrinth.  They  are  of  a  different 
character  and  origin  from  the  cysts  of  the  maxillary  sinus.  In  the 
ethmoid  it  was  found  that  the  exaggerated  de^'elopment  or  patho- 
logical processes  sometimes  led  to  a  cyst  cavity  formed  out  of 
the  bulla  or  other  small  cell  at  the  anterior  end  of  the  middle 
turbinate.  This  was  occasionally  found  to  contain  pus  or  a 
glairy  mucus.  The  cause  of  the  cysts  occasioned  some  discussion. 
Their  occurrence  chieflj^  in  women  is  a  curious  phenomenon  of  sex 
pathology,  Zuckerkandl,  Glasmacher,-  ]\IacBride,^  Knight/  and 
others  noted  their  occurrence,  and  various  theories  were  advanced 
as  to  their  pathogenesis,  but  it  was  not  until  the  publication  of 
Stieda,^  in  1895,  that  it  was  recognized  that  they  are  the  products 
of  inflammatory  action  set  up  in  the  walls  of  preexisting  mucosa 
lined  cavities  in  the  turbinated  bones,  whereby  the  osteoblasts, 
forming  bone  on  the  outer  or  convex  surface  and  osteoclasts, 
absorbing  it  on  the  concave  or  inner  surface,  we  have  as  a  result 
in  some  cases  the  formation  of  a  very  large  cavity.*^  A  very  excep- 
tional report  was  made  by  Xoltenius,'  in  1895,  of  37  cases  of  "serous 
disease"  of  the  maxillary  sinus  in  which  on  exploratory  puncture 
clear  fluid  was  washed  from  the  antrum.  The  large  number  of 
cases  reported  by  one  observer  attracted  attention  and  is  still 
unique,  though  a  less  number  of  cases  have  from  time  to  time  been 
reported,  usually  supposed  to  be  due  to  cyst  formation  in  the 
antrum.  Cysts  of  the  mucous  membrane  of  the  maxillary  antrum 
were  exhaustively  described  by  Alexander,^  and  the  differential 
diagnosis  of  this  condition  from  antrum  empyema  was  the  subject 
of  a  paper  by  Kunert^  in  1897.  Gerber^°  and  Shambaugh,"  in  1906, 
wrote  of  nasal  cysts  in  the  nose  and  maxillary  sinus,  their  relation 
to  the  "hytlrops"  of  the  latter,  and  their  embryogenetic  origin 
from  the  teeth  roots.  Hoffmann,^-  in  1911,  extended  his  previous 
observations  (1902)  on  cysts  of  the  maxillary  sinus  in  which  he 
described  his  histological  findings  in  cases  of  dental  origin.  Oppi- 
kofer^^  also  contributed  an  exhaustive  article  in  191 1  to  the  literature 

1  Onodi:  Archiv  fiir  Laryngologie  und  Rhinologie,  1904,  XV,  p.  306. 
'  Glasmacher:  Berliner  klinische  Wochenschrift,  1884,  XXI,  p.  571. 
3  MacBride:  British  Medical  .Journal,  1888,  II,  p.  1116. 

*  Knight:  Transactions  American  Laryngological  Ass'n,  1891,  p.  57. 

*  Stieda:  Ai-chiv  fiir  Laryngologie,  1895,  III,  p.  3.59. 

^  Wright:  New  York  Medical  Jom-nal,  June  27,  1896,  Ixiii,  p.  827.  American 
Journal  of  the  Medical  Sciences,  May,  1907,  Vol.  133,  p.  760. 

'  Noltenius:  Monatsschrift  fiir  Ohrenheilkunde,  No.  4,  1895,  XXIX,  p.  114. 

8  Alexander:  Berliner  khn.  Woc-henschrift,  1897,  XXXIII,  p.  103. 

'  Kunert:  Archiv  fiir  Laryngologie  und  Rhinologie,  1897,  VII,  p.  34. 

1"  Gerber:  Archiv  fiir  Laryngologie  und  Ilhinologie,  1904,  XVI,  p.  502. 

"  Shambaugh:  The  Laryngoscope,  July,  1906,  XVI,  p.  527. 

12  Hoffmann:  Zeitschrift  fiir  Laryngologie  und  Rhinologie,  1911,  III,  p.  467. 

"  Oppikofer:  Verhandlung  des  Vereins  dcutscher  Laryngologen,  1911,  p.  613. 
Archiv  fiir  Laryngologie  und  Rhinologie,  1911,  XXV,  Heft  1,  p.  45. 


276  THE  ACCESSORY  NASAL  SINUSES 

of  dental  cysts  describing  fully  a  number  of  cases  and  the  histological 
findings,  while  many  joints  in  their  ])atli()gcnesis  are  yet  unex- 
plained, lie  seemed  to  think  it  clear  tiiat  they  have  their  origin 
in  inflannnation  of  the  roots  of  the  teeth  and  their  envelopes — 
caries  and  granulation  tissue  representing  the  initial  stage  of  their 
formation.  There  is  probably  a  proliferation  of  the  epithcHuni 
thus  aroused  with  a  subsequent  degeneration  of  the  epitiielium 
furnishing  the  fluid  contents  of  the  cyst,  tiiough  this  is  one  of  the 
points  far  from  settled. 

Teeth  in  the  Nose. — Intimately  connected  Avith  the  subject  of 
dental  cysts  of  the  maxillary  sinus  are  those  anomalies  of  develop- 
ment of  the  teeth  in  the  upper  jaw  which  lead  not  only  to  cysts 
of  their  roots  but  to  displacement  and  inversion  of  tlieir  crowns 
and  the  wandering  of  the  teeth  through  the  bon\'  walls  of  the 
superior  maxillae.  Naturally  many  of  these  become  inhabitants 
of  the  maxillary  sinus  and  instances  of  this  had  been  noted  even 
in  prelaryngoscopic  days  by  the  poet  Goethe  and  early  in  the 
study  of  sinus  disease  we  find  many  reports  in  literature.^  A  number 
of  cases  of  teeth  in  the  nose  and  nasal  sinuses  have  been  reported 
in  the  last  two  or  three  years.^  Underwood^  contributed  an  article 
in  1910  to  the  anatomy  and  pathology  of  the  maxillary  sinus  in 
which  he  dealt  with  its  embryogenetic  origin  in  connection  with 
the  teeth,  comparing  conditions  in  various  races  of  men. 

Mucocele. — Mucocele  of  the  accessory  sinuses,  a  rare  condition 
which  liad  been  noted  by  Kuhnt,  was  described  by  Avellis,'*  in  1900, 
by  Baurowicz/  in  1901,"  by  Bowlby,«  in  1902,  by  Guisez/  in  1903, 
and  l)y  Onodi^  and  Moure,^  in  1905.  Since  then  there  have  been  a 
very  large  lunnber  of  reports  recorded. 

Malignant  Tumors. — Rejwrts  of  malignant  tvnnors  located  in 
the  accessory  siimses  may  be  found  scattered  through  general 
literature  from  almost  the  very  beginning  of  medical  records,  and 
I  shall  have  to  content  myself  with  brief  reference  to  those  reports 
for  five  years  following  the  paper  of  Schwenn,^''  inasmuch  as  in 
laryngological  literature  this  is  the  first  extended  reference  especiallx' 

1  Wright:  Tlie  Medical  Record,  October  12,  1889,  XXXVI,  p.  396.  Wright: 
The  Medical  Record,  May  19,  1894,  XLV,  p.  641.  Knapp:  Archives  of  Otology, 
1894,  XXllI,  p.  71.  Duel:  N.  Y.  Medical  Journal,  December  1,  1900,  LXXII, 
p.  92S.  Liaras:  Ref.,  N.  Y.  Medical  Journal,  November  17,  1900,  LXXII, 
p.  868. 

-  See  Semon's  Internal.  Centralblatt  fiir  Larvngologic  und  Rhinologie,  1911, 
XXVII,  p.  399. 

^  Underwood:  Journal  of  Anatomy  and  Physiology,  Jul}-,  1910,  XLIV,  p.  354. 

*  Avellis:  Art^hiv  fiir  Laryngologic  und  Rhinologie,  1900,  Band  X,  p.  1. 

*  Baurowicz:  Archiv  fiir  Laryngologic  und  Rhinologie,  1901,  XII,  p.  303. 
«  Bowlby:  British  Medical  Journal,  May  3,  1902.  I,  p.  1084. 

'  Guisez:  Annales  d.  Mai.  dc  rOroillo,  1904,  XXX,  Ft.  I,  p.  irD2. 
"  Onodi:  Archiv  fin-  Laryngologic  und  Rhinologie,  1905,  XVII,  p.  415. 
"  Moure:  R6vue  hebdomadaire  de  Laryngologie,   Rhinologie,   etc..    No.    1, 
1905,  XXV,  Pt.  I,  p.  4. 
^"Schwenn:   Archiv  fiir  Laryngologie  und  Rhinologie,  1900,  XI,  p.  351. 


SINUS  OZ^NA  277 

confined  to  malignant  tumors  of  these  cavities.  In  1900  he  reported 
ten  cases  of  malignant  tumors  in  the  accessory  sinuses,  two  in  the 
maxillary,  seven  in  the  ethmoid,  one  in  the  sphenoid.  Kirschner, 
Brindel,  Citelli,  Onodi,  Avellis,  Harmer,  and  Calamida^  were  the 
chief  reporters  of  cases  of  malignant  sinus  disease  from  1900  to 
1900,  hut  since  then  many  more  cases  may  be  found  on  record. 

Choanal  Polypi. — ObserAations  were  made  by  several  writers- 
who  called  attention  to  the  fact  that  many  of  the  nasal  polypi, 
especially  those  presenting  posteriorly  in  the  choana^,  had  their 
origin  from  and  were  attached  to  the  upper  part  of  the  maxillary 
sinus  and  in  the  hiatus  semilunaris  and  not  in  the  nasal  chambers 
proper.  Kubo  proposed  to  operate  on  these  by  first  exposing  their 
base  of  attachment  by  the  external  operation  (canine  fossa)  on 
the  maxillary  sinus.  Subsequent  discussion  has  shown  that  by  no 
means  all  polypi  are  thus  attached.  It  seems  prol)able  that  this 
origin  when  existing  is  found  only  in  cases  of  the  soft  oedematous 
polypi,  not  of  the  hard  growths  of  adolescence.^ 

Sinus  Tuberculosis. — Weichselbaum,*  in  an  article  on  nasal  tuber- 
culosis in  1S81,  referred  to  it  as  occurring  in  the  accessory  sinuses. 
Three  or  four  cases  of  tuberculosis  of  the  ethmoidal  labyrinth  have 
been  reported^  since  then.  . 

Rhinitis  Caseosa. — Cozzolino  at  the  International  Congress  ff)r 
Otology  and  Laryngology  in  1889  had  spoken  of  rhinitis  caseosa 
or  cholesteatomatosa  as  a  disease  in  itself.  Subsequently  it  became 
evident  that  it  was  a  peculiar  caseation  of  the  retained  nasal 
discharges  excited,  often  by  the  presence  of  a  foreign  body,  but  also 
in  cases  of  retention  of  pus  in  the  sinuses  extending  over  long  periods 
of  time." 

Sinus  Ozaena. — Robertson,^  in  P^ngland,  in  1893,  advocated  the 
ideas  both  of  Woakes  as  to  the  origin  of  nasal  polypus  and  of 
Griinwald  as  to  the  origin  of  ozaena.     Alexander,*  in  1909,  seems 

^  Kirschner:  Archiv  fiir  Laryngologie  unci  Rhinologie,  1904,  XV,  p.  1. 
Brindel:  Gazette  hebdomadaire  des  sciences  medicales  de  Bordeaux,  No.  12, 
1904,  XXV,  p.  139.  Citelli:  Archiv  fiir  Laryngologie  und  Rhinologie,  1904, 
XV,  p.  252.  Bar  til  and  Onodi:  Archiv  fiir  Laryngologie  und  Rhinologie,  1903, 
XV,  p.  167.  Avellis:  Verhandlungen  d.  Vereins  Siiddeutscher  Laryngologen, 
June  12,  1905,  p.  49.  Harmer:  Internat.  Centralblatt  fiir  Laryngologie,  1905, 
XXI,  p.  539.  Calamida:  Archives  Internationales  de  laryngologie,  etc.,  iVIarch, 
April,  1905,  XIX,  p.  385. 

^Lermoyez:  Ann.  d.  mal.  de  I'oreille,  1909,  XXXV,  Pt.  I,  p.  fiOl.  Kubo: 
Archiv  fiir  Laryngologie,  190(S,  XXI,  p.  82. 

^  Jacques:  Archiv  fiir  Laryngologie,  1911,  XXV,  p.  318. 

■*  Weichsclbaum :  Allgemeine  Wiener  niedizinische  Zeitung,  No.  27-28,  1881, 
XXVI,  pp.  268,  277. 

°  Find(T:  Charitc  Annalen,  19n,  XXXV,  p.  .')()5. 

^  Hartmann:  Deutsche  niedizinische  Wochenschrift,  No.  10,  1889,  XV,  p. 
190.  Strazza:  Bollctino  delle  nialattie  dell'orechio,  della  gola,  etc.,  No.  9, 
1893,  XI,  p.  199.  Bryan:  N.  Y.  Medical  Jovn-nal.  January  28,  1893,  LVII, 
p.  97.    Khngel:  Archiv  fiir  Laryngologie  luid  Rhinologie,  1895,  111,  p.  199. 

">  Robertson:  The  Lancet,  April  29,  1893,  1,  p.  983. 

^Alexander:  Archiv  fiir  Laryngologie  und  Rhinologie,  1909,  XXII,  p.  260. 


278  THE  ACCESSORY  NASAL  SINUSES 

to  voice  the  present-f]ay  opinion  tliat  the  only  foundation  for  the 
contention  of  Grihiwald  that  ozaMia  is  a  disease  of  the  accessory 
sinuses  lies  in  the  fact  that  atrophic  rhinitis  and  ozaMia  are  primarily 
a  bone  disease  and  the  accessory  sinuses  are  involved  in  the  changes 
of  the  mucosa  producing  ozsena  just  insofar  as  their  bony  walls 
are  involved  in  the  general  pathological  process  of  the  frame-work 
of  the  nasal  chambers.  I  omit  mention  here  of  the  very  large  num- 
ber of  papers  and  discussions  which  have  occurred  since  the  publica- 
tion of  the  ])ai)ers  of  (rriinwald,  in  which  his  views  are  upheld, 
because  they  rest  largely  on  clinical  observations,  uncontrolled  by 
postmortem  exammation  and  unenlightened  by  a  knowledge  of 
histological  findings. 

Embryogeny  of  the  Sinuses. — The  exhaustive  iuAcstigations  of 
Killian  had  shown  the  embryogenetic  explanation  for  many 
anomalies  in  the  anatomy  of  the  frontal  sinuses  and  these  came 
to  light  in  the  practical  observations  of  those  practising  the  various 
forms  of  frontal  sinus  operations. ^  Anomalies  in  the  configuration 
of  the  frontal  sinuses  had  been  early  noted.  The  absence  of  one  or 
the  other,  the  presence  of  septa  partial  or  comjilete  dividing  them 
into  compartments  or  pockets,  often  much  embarrassed  the  opera- 
tors. These  anomalies  occasionally  led  to  perforations  through 
the  bone  and  to  the  wounding  of  the  dura  or  even  of  the  brain 
substance.  Compartments  were  left  unopened  or  incompletely 
drained  and  other  complications  were  met  with.  ]\Iany  of  these 
difficulties  were  avoided  after  the  introduction  of  the  use  of  the 
ar-ray  in  diagnosis.  It  is  to  the  embryogenetic  and  the  gross  ana- 
tomical studies  of  Sieur  and  Jacob,  Killian,  Onodi,  and  others  that 
we  must  return  in  order  to  take  up  the  thread  of  original  observa- 
tion which  led  to  the  great  advance  in  the  therapy  and  operative 
technicpie  of  sinus  disease.  In  1S95  Killian-  published  his  first 
articles  on  the  anatomy  of  the  nose  of  the  human  embryo  and  in 
these  articles  he  extended  and  made  more  exact  and  definite  the 
work  of  Zuckerkandl  and  laid  the  foundation  for  his  later  develop- 
ment of  the  surgery  of  the  accessory  sinuses.  In  England  Tilley^ 
published  some  work  on  the  surgical  anatomy  of  the  frontal  and 
ethmoid  sinuses  in  which  attention  was  drawn  to  their  variability. 
In  America  Bryan,^  in  1895,  and  ]\Iyles,''  in  1896,  pul)lished  valuable 
papers  in  which  the  anatomy  and  surgery  of  the  accessory  sinuses 
were  discussed.    Subsequently  in  America  Coakley  was  an  earnest 

1  Hartmann:  Verhandlungcn  dor  Ciesellschaft  deutscher  Naturforscher  und 
Aerzte,  1898,  2  th.,  2  halfte,  p.  287.  Stewart:  Lancet,  December  10,  1898, 
II,  p.  1547. 

2  Killian:  Archiv  fiir  Laryngologie,  1895,  II,  p.  234,  1895,  III,  p.  17;  1896, 
IV,  p.  1. 

3  Tilley:  Lancet,  September,  1896,  II,  p.  866. 

*  Bryan:  Transactions  American  Laryngological  Ass'n,  1895,  p.  76. 
^  Mylos:  Medical  News,  March  28,  1896,  LXVIII,  ]).  339;  Medical  News, 
August  7,  1897,  LXXI,  p.  161. 


ANATOMY  OF  THE  SINUSES  279 

and  enthusiastic  operator  on  the  accessory  minuses  and  communi- 
cated many  papers  to  the  literature  of  the  subject.  I^athrop/  in 
1S9S,  pubhshed  a  brochure  on  the  subject  of  the  anatomy  of  the 
frontal  and  ethmoid  cells,  which  remains,  with  Loeb's  publications, 
America's  most  important  contribution  to  the  subject.  Sieur^ 
and  Jacob  published  in  1901  an  extensive  and  valuable  work  on 
the  embryogeny  of  the  accessory  sinuses  and  upon  the  anatomical 
relations,  which  was  the  foundation  for  much  subsequent  work 
in  France  and  America. 

Anatomy  of  the  Sinuses. — At  the  meeting  of  the  Society  of  Hun- 
garian Ear  and  Throat  Specialists  in  1900  Onodi-^  demonstrated  his 
anatomical  preparations  of  the  accessory  sinuses  which  formed 
the  basis  of  his  later  work  which  has  done  so  much  to  clear  up  many 
obscure  points  and  throw  light  for  the  first  time  on  some  hitherto 
unknown  or  rather  unheeded  relationships  of  importance.  His 
work"*  on  the  relationship  of  the  posterior  ethmoidal  cells  and  of 
the  sphenoidal  cavity  to  the  optic  nerves  is  especially  noteworthy. 
The  embryological  studies  of  Killian  were  later  supplemented  by 
a  profusely  illustrated  treatise-^  on  the  anatomy  of  the  sinuses 
which  with  Onodi's  work  ha\'e  formed  the  sources  from  which 
most  of  the  subsequent  papers  have  drawn  their  embryological 
and  anatomical  information.  In  1903  Br iihl,'^  Hansen  and  Pluder/ 
and  Onodi**  made  observations  on  the  irregularities  in  the  anatomy 
of  the  frontal  sinuses.  IMosher  and  IngersolP  in  America  extended 
the  work  of  Sieur  and  Jacob.  Some  attempts^"  had  been  made  to 
establish  a  reliable  measurement  by  which  one  could  know  with 
the  probe  that  the  anterior  or  posterior  wall  of  the  sphenoid  sinus 
was  reached  in  intranasal  operations,  but  it  was  not  until  the  paper 
of  Onodi,"  in  1904,  that  the  importance  of  the  knowledge  of  the  size, 
relative  distances  from  a  fixed  point,  etc.,  were  fully  appreciated 
in  the  surgery  of  the  accessory  sinuses.  Nothing  has  surpassed 
the  plates  and  diagrams  of  sections  of  the  nose  and  its  adnexa 

^  Lathrop:  Frontal  Sinus  and  Ethmoid  Cells;  Warren  Triennial  Prize,  1898, 
with  addition  of  Part  II  on  the  Clinical  and  Surgical  Aspects  of  Sinus  Disease. 

-Sieur:  Revue  hebdomadaire  de  larj'ngologie,  No,  38,  1901,  XXI,  Pt.  2, 
p.  337;  also  Thierry  and  martel:  Annales  des  maladies  de  I'oreille,  etc.,  April, 
1905,  XXXI,  Pt.  1,  p.  380. 

^  Onodi:  Archiv  flir  Laryngologie  und  Rhinologie,  1900,  XI,  391. 

*  Onodi:  Ai-chiv  fiir  Laryngologie  und  Rhinologie,  1904,  XV,  Heft  2,  p.  259; 
1905,  XVII,  p.  260. 

^  Killian :  Die  Nebenhohle  der  Nase  and  ilire  Lagcbeziehungen  zu  den  Nach- 
barorganen,  Jena,  1903. 

«  Briihl:  Zeitschrift  fiir  Ohrenheilkunde,  1902,  XL,  p.  343. 

^  Hansen  and  Pluder:  Archiv  fiir  Laryngologie  und  Rliinologie,  1903,  XIV, 
p.  404. 

^  Onodi:  Archiv  fiir  Laryngologie  und  Rhinologie,  1904,  XV,  p.  303. 

^  Mosher  and  Ingersoll:  Transactions  American  Laryngological  Ass'n,  1904, 
pp.  319,  270. 

10  Wright:  Twentieth  Century  Practice  of  Medicine,  1896,  vol.  vi,  p.  79. 
Hajek:  Pathologic  und  Therapie  der  Nebcnluihlon  der  Nase,  Leipzig,  1899. 

"  Onodi:  Archiv  fiir  Laryngologie  und  Rl)inologie,  1904,  xvi,  p.  454. 


280  THE  ACCESSORY  NASAL  SINUSES 

■which  lie  furnished  in  tliis  and  other  papers.  Especiall\'  valuable 
is  his  work  on  the  relations  of  the  optie  nerves  to  the  walls  of  the 
l^osterior  ethmoidal  and  sphenoidal  sinuses  (1.  e.).  It  may  be  said 
that  these  contributions  of  Onodi  with  the  earlier  ones  of  Sieur 
and  -lacob  and  those  of  Killian  form  by  far  the  most  valuable 
a(hlitions  to  the  still  earlier  work  of  Zuekerkandl  which  exist  in 
medical  literature.  For  five  years  there  was  not  much  more  oriuinal 
work  attem])ted  of  this  kind.  Griinwald'  contributed  a  \aluable 
article  in  11)10  to  the  literature  of  the  anatomy  of  the  sinuses  from 
their  embryogenetie  standpoint  as  derivatives  of  the  hiatus  semi- 
lunaris, illustrated  by  clinical  ])henomena  as  observed  in  practice, 
pointing  out  that  the  proximity  of  these  cavities  in  the  embryo  to 
the  lateral  nasal  furrow  serves  as  an  explanation  of  inflammatory 
and  teratological  processes  in  the  maxillary  sinus  and  in  the  regions 
lying  between  the  eye  and  nose.  The  same  subject  was  treated 
by  Schaeffer-  at  this  time.  Onodi,''  in  1911,  published  a  brochure 
with  his  usual  excellence  of  illustration  and  of  detail  on  the  nasal 
sinuses  of  children.  A  number  of  cases  of  em])yema  of  tlie  sinuses 
in  children  had  been  obser^"ed.  Canestro^  reported, in  \[)l  1 ,  empyema 
of  the  maxillary  siiuis  in  a  child  twenty-six  days  old  and  collected 
other  reports  in  literature  and  made  some  anatomical  studies  of 
the  accessory  sinuses  in  infants  which  made  it  evident  that,  though 
rarely,  the  sinuses  may  be  the  seat  of  disease  before  they  are  fully 
developed.  Loeb  at  the  International  Laryngological  Congress 
(1911)  and  elsewhere,  detailed  his  investigations  of  the  cubic 
capacity  and  square  surface  of  the  accessory  sinuses. 

These  were  the  beginnings  and  the  course  of  that  anatomical 
and  pathological  inquiry,  incompletely  detailed  here,  it  is  true, 
which  has  been  devoted  to  the  study  of  sinus  disease,  acting  at 
first  as  a  stimulus  and  more  recently  as  a  guide  to  surgical  })rocedure. 
Certain  advances  in  the  methods  of  diagnosis  must  now  be  alluded 
to,  though  it  is  quite  impossible  to  find  space  to  set  forth  fully  the 
evolution  of  that  diagnostic  acumen  which  has  become  the  posses- 
sion of  all  competent  rhinologists.  Clinical  experience  has  played 
the  most  important  part,  yet  it  is  only  possible  here  to  refer  to 
the  chief  aids  in  the  clinical  study  of  simis  disease  which  have 
made  diagnosis  more  accurate. 

Rontgenology  in  Sinus  Disease. — I  have  already  referred  as 
fully  as  space  allows  to  the  early  history  of  transillumination. 
In  natural  sequence  we  come  to  speak  of  rontgenology  in  the 
service  of  the  study  of  sinus  disease.  On  September  24,  1S9G, 
]\Iax    .Scheier'^  made    an   address  before  the  ^Society  of   (lerman 

'  Griinwald:  Archiv  fiir  Liiryngologic  und  Rhinologie,  1910,  xxiii,  p.  183. 
2  Schaeffer:  Annals  of  Otology,  Rhinology  and  Laryngology,  December,  1910, 
xix,  p.  815. 

^  Onodi:  Die  Nebenhohle  der  Nase  beim  Kindo,  1911. 

*  Canestro:  Archiv  fiir  Laryngologie.  1911,  XXV,  llcft  3,  p.  492. 

'  Schfier:  Archiv  fiir  Larj-nfiologie  und  Rhinologie,  1897,  VI,  j).  ")7. 


RONTGENOLOGY  IN  SINUS  DISEASE  281 

Scientists  and  Physicians  at  Frankfort  on  the  vakie  of  the  Rontgen 
rays  in  the  diagnosis  of  affections  of  the  nose  and  throat.  Tlie 
outhnes  of  the  accessory  sinuses  can  hardly  be  seen  in  his 
])lates  but  sufficient  was  demonstrated  to  act  as  an  incentive  for 
future  endeavor.  It  has  resulted,  for  the  diagnosis  of  accessory 
sinus  disease,  in  the  development  of  one  of  the  most  valuable  aids 
we  have  in  ascertaining  the  limits  of  purulent  involvement  of  the 
sinuses.  In  connection  with  other  adjuvants,  in  spite  of  much 
disappointment  inevitable  on  the  advent  of  a  new  device  in  medicine 
due  to  exaggerated  claims,  it  seems  to  have  established  itself  as  a 
much  more  valuable  procedure  than  transillumination  which  also 
had  its  day  of  exaggerated  enthusiasm  and  is  still  after  judicious 
criticism  indispensable  to  the  armamentarium  of  the  rhinologist. 
It  was,  however,  a  number  of  years  before  this  aid  in  the  diagnosis 
reached  a  stage  of  practical  value.  The  complicated  labyrinth 
of  cavities  and  their  bony  walls  which  go  to  make  up  the  anatomy 
of  the  nasal  chambers  and  their  adnexa  presented  a  problem  of  very 
great  difficulty  to  the  rontgenologist.  ]Many  eft'orts,  most  of  them 
too  technical  for  detail  here,  were  made  to  overcome  these  obstacles. 
In  1903  Weil  proposed  the  introduction  into  the  maxillary  sinus 
of  substances  forming  a  shadow  with  the  .r-rays  in  order  to  demon- 
strate its  anatomical  configuration  and  pathological  state.  This 
proved  of  little  assistance  and  the  difficulty  of  introduction  and 
withdrawal  of  such  powders  has  made  it  impracticable  and  unwise. 
Some  cases  were  subsequently  reported  where  such  material  acted 
as  an  irritating  foreign  substance  in  the  cavities.  The  chief  improve- 
ments in  skiagraphy  have  been  the  technical  ones  of  a  more  efficient 
apparatus  both  electric  and  photographic.  Coakley^  in  America 
recognized  the  value  of  skiagraphy  in  the  diagnosis  and  differentia- 
tion of  separate  sinus  affections  and  was  active  in  developing  its 
application  to  sinus  diagnosis.  Herzfeld-  in  criticism  of  the  work 
of  Kuttner,^  an  atlas  published  in  1908  with  20  plates,  brought 
out  a  discussion  in  the  Berlin  Laryngological  Society  (December 
11,  1908)  whereby  it  was  apparent  that  by  this  time  the  consensus 
of  opinion  was  that  rontgenology  had  furnished  a  valuable  aid 
in  the  diagnosis  of  sinus  disease,  but  the  shortcomings  and  unreli- 
ability of  it  as  an  exclusive  indication  for  operation,  or  even  as  an 
indication  of  the  existence  of  disease,  w^ere  still  very  great.  In 
this  and  subsequent  meetings  Peyser,  Killian,  Al])recht,  and  others 

1  Coakley:  Annals  of  Otology,  Rhinology  and  Laiyngology,  March,  1905, 
XIV,  p.  16;  Transactions  American  Laryngological  Ass'n,  1905,  p.  222. 

-  Herzfeld:  Beitriigc  zur  Anatomic,  Physiologic,  Pathologie  und  ThorajMc 
des  Ohres,  der  Nase  und  dcs  Halses,  1909,  II,  p.  346. 

^  Kuttner:  Die  entziindlichen  Nebenhohlcncrkrankimgen  der  Xase  im  Rocnt- 
genbild,  Berlin,  1908.  See  also  Spiess:  Die  lioontgenuntersuchung  der 
oberen  Luftwege.  Atlas  und  Grundriss  der  Roentgendiagnostik  in  der  inneren 
Medicin.  herausg.  v.  Franz  M.  Grocdcl.  (Lehmann's  medizinische  Atlanten, 
Miinchen,  1909,  Band  7,  p.  15. 


282  THE  ACCESSORY  NASAL  SINUSES 

expressed  themselves  to  this  effect.  Although  Alhrecht's^  reproduc- 
tions mark  a  distinct  advance  over  former  work  in  Germany,  his 
plates  have  been  surpassed  by  other  workers  in  America.  (  aldwell- 
had,  in  1908,  far  surpassed  all  competitors,  but  the  recent  exhil)ition 
of  stereoscopic  plates,  giving  the  perspective  of  relationship  of  the 
sinuses  to  one  another,  seems  to  have  brought  the  art  to  its  acme 
of  development.^  Ilaike^  published  a  paper  in  1010  upon  the 
skiagra})hic  examination  of  the  accessory  sinuses  of  children  whereby 
some  light  was  gained  in  the  knowledge  of  their  deAciopment  and 
in  the  diagnosis  of  the  pathological  conditions  which  occasionally 
are  present  in  them.  A  number  of  rhinologists  used  the  .r-ray  in 
the  treatment  of  affections,  other  than  malignant  tumors,  in  the 
accessory  sinuses,  but  without  success,^  so  far  as  one  can  judge 
from  the  reports  and  the  fact  that  the  procedure  has  been  little 
used  and  has  received  little  mention.  There  have  been  some 
favorable  reports  of  the  .r-ray  treatment  of  malignant  tumors''  in 
the  sinuses. 

Diagnostic  Irrigation. — Krause,^  Lichtwitz,  INIyles  and  Onodi 
had  de\'ise(l  cur\'C(_l  trocars  and  cannulas  for  perforation  of  the  walls 
of  the  maxillary  sinus  above  or  below  the  middle  turbinate  for 
purposes  of  irrigation.  As  early  as  189G  Killian^  made  use  of  these 
in  detecting  the  presence  of  pus  in  the  Antrum  of  Ilighmore  by 
washing  it  out  of  the  hiatus  semilunaris  by  the  stream  of  fluid 
introduced  through  the  canuia. 

Negative  Pressure  in  Diagnosis. — Seifert^  and  Retlii'''  by  using 
the  Pollitzer  bag  for  inflation  of  the  ear  in  such  a  manner  that  on 
the  expansion  of  the  bulb  a  negative  pressure  is  exerted  in  the 
nose,  initiated  a  method  of  diagnosis  of  accessory  sinus  disease 
which  depends  on  the  suction  of  pus  from  the  recesses  to  the  nasal 
passages  where  its  visibility  furnishes  a  guide  to  the  sinus  contents. 
Sondermann"  and  Spiess^-  devised  more  effective  apparatus  for 
producing  negative  pressure  in  the  nasal  chambers.  This  procedure 
they  claimed  to  have  a  therapeutic  value  in  the  treatment  of  certain 

^  Albrecht:  Archiv  fiir  Laryngologic  unci  Rhinologie,  1908,  XX,  p.  175. 

^  Caldwell:  The  Laryngoscope,  November,  1908,  XVIII,  p.  853. 

'  See  also  Turner  and  Porter :  The  Skiagraphy  of  the  Accessory  Nasal 
Sinuses,  Edin.,  1912. 

^  Haike:  Archiv  fi'ir  Laryngologic  und  Rhinologie,  1910,  XXIII,  p.  206. 

^  See,  for  instance,  Mader:  Archiv  fiir  Laryngologic  und  Khinologie,  1906, 
XVIII,  p.  1. 

"  Freudenthal:  Annals  of  Otology,  Laryngology  and  llhinology,  1912. 

'  Krause:  Monatsschrift  fiir  Ohrcnhcilkundc,  No.  3,  1887,  XXI,  p.  70. 

^Killian:  Miinchener  medizinische  Woehenschrift,  No.  31,  1896,  XLIII, 
p.  723. 

'•Seifert:  Sitzungs-Berichfe  d.  jihysikalisch  medizinischen  Gesellschaft  zu 
Wurzburg,  April  29,  1899,  p.  80 

»»  Rethi:  Wiener  klin.  Rundschau,  1899,  XIII,  p.  745. 

'^  Sondcrmann:  Miinchener  medizinische  Woehenschrift,  1905,  LII,  p.  17. 
Archiv  fiir  Laryngologic  imd  Rhinologie,  1905,  X\'II,  p.  425. 

'^  Spiess:  Archiv  fiir  Laryngologic  und  Rliinologie,  1905,  XVII,  p.  179. 


FRONTAL  SINUS  OPERATIONS  283 

nasal  affections,  but  this  has  not  been  sustained.  Its  chief  value 
remains  the  diagnostic  one.  By  sucking  the  contents  out  of  the 
openings  of  the  accessory  sinuses  into  the  middle  meatus  where  it 
can  be  seen  in  rhinoscopy  permits  the  observer  to  detect  latent  sup- 
puration of  the  cavities.  Of  course  it  has  not  always  proved  effica- 
cious in  accomplishing  its  purpose,  but  it  has  often  proved  useful  in 
avoiding  the  necessity  for  perforating  the  maxillary  sinus  with  trocar 
and  cannula  and  washing  out  the  contents  of  the  cavity  for  diagnostic 
purposes,  a  painful,  at  least  an  unpleasant,  proceeding,  and  one  not 
always  unattended  by  danger.^  Claus-  reported  four  cases  of 
death  from  puncture  and  washing  out  the  maxillary  sinus,  one  at 
least  apparently  from  the  introduction  of  air  into  a  vein.  A'arious 
contri\-ances  of  a  suction  pump  driven  by  electricity  or  otherMise 
have  thus  become  very  useful  additions  to  the  rhinologist's  arma- 
mentarium. 

Endoscope. — As  early  as  1902-3^  attempts  were  made  to  invent 
an  endoscope  by  means  of  which  closer  and  more  minute  inspection 
might  be  made  of  the  walls  of  the  sinuses  when  introduced  in  the 
nose  or  through  artificial  openings  in  the  sinuses  themselves,  espe- 
cially the  maxillary.  INIore  recently  Tovolgyi*  has  devised  an 
instrument  by  means  of  which  the  maxillary  antrum  is  punctured 
and  through  the  endoscopic  cannula  its  walls  inspected.  He  called 
it  "x\ntroskoptrocar." 

Frontal  Sinus  Operations. — Ogston^  in  referring  to  his  own  attempts 
to  do  so  had  declared,  in  1884,  that  there  was  no  possibility  of  intro- 
ducing a  probe  into  the  frontal  sinus  from  the  passages  below. 
Subsequent  work  slowly  but  finally  fully  demonstrated  the  essential 
error  of  this  assumption.  I  ha\'e  already  referred  to  the  early 
proposition  of  Schaeft'er  and  Lichtwitz  to  open  the  frontal  sinus 
through  the  nose.  This  did  not  meet  with  fa\'or  at  the  time,  though 
Winckler,^  in  1893,  did  much  to  show  the  surgical  relations  of  the 
frontal  sinus  with  the  upper  nasal  passages  were  such  as  to  suggest 
its  practicability.  In  this  he  was  supported  by  Scheier.'^  Very 
early  it  was  recognized^  that  acute  frontal  sinus  inflammation  in 
the  great  majority  of  cases  recover  spontaneously  and  that  it 
is  necessary  to  distinguish  carefully  in  this  respect  the  indications 
for  operation;  but  when  an  operation  is  necessary  the  whole  drift 

^  Menzel:  Archiv  fiir  Laryngologie  und  Rhinologie,  1905,  XVII,  p.  371. 

^  Claus:  Beitriige  zur  Anatomie,  Physiologic,  Pathologie  und  Thcrapie  des 
Ohres,  der  Nase  und  dos  Halses,  1910,  IV,  p.  8S. 

^  Reichert:  Berliner  klin.  Wochensch.,  1902,  XXXIX,  p.  401.  Hirschmann: 
Ibid.,  1902,  XXXIX,  p.  478.  Archiv  fur  Laryngologie  und  Rhinologie,  1903, 
XIV,  Heft  2,  p.  19.5. 

*  T6v6lgyi:  Archiv  fiir  Laryngologie  und  Rhinologie,  1911,  XXV,  p.  144. 
5  Ogston:  The  Medical  Chronicle,  December,  1884,  I,  p.  235. 

^  Winckler:  Archiv  fiir  Laryngologie  und  Rhinologie,  1893,  I,  p.  178;    1895, 
II,  p.  138. 
'  Scheior:  Wiener  medizinische  Presse,  No  10,  1898,  XXXIX,  p.  365. 

*  Herzfeld:  Deutsche  medizinische  Wochenschrift,  No.  12,  1895,  XXI,  p.  195. 


284  THE  ACCESSORY  NASAL  SINUSES 

of  opinion  for  ten  years  was  toward  ,<;:aiiiinjj  access  to  the  sinus  by 
means  of  an  external  ojxTation.  Tilley,'  in  ]S9(i,  made  a  study  of 
the  sur^'ieal  aiiatomy  of  the  frontal  sinus  and  urged  this  route. 
In  many  subsequent  papers  and  at  almost  every  meeting  of  laryn- 
gologists  in  Great  Britain  and  in  many  elsewhere  this  earnest 
worker  has  contributed  to  the  literature  of  the  subject.  Cases  of 
brain  abscess  complicating  frontal  sinus  suppuration  began  to  be 
frequently  reported.'-  In  France,  Luc*  was  active  and  influential 
in  the  development  of  knowledge  of  accessory  sinus  disease,  and 
he  also  had  occasion  to  note^  the  occurrence  of  meningeal  infection 
after  an  operation  on  a  tumor  of  the  frontal  sinus.  In  1884  Ogston 
(1.  c.)  had  operated  on  the  frontal  sinus  by  an  angular  incision,  a 
vertical  one  along  the  wrinkles  between  the  eye})rows  meeting  a 
horizontal  incision  ])arallel  to  the  wrinkles  of  the  brow.  Skin  and 
periosteum  being  raised  he  applied  a  trephine  to  the  bone  and  made 
a  large  enough  ()i)ening  to  expose  the  contents  of  the  sinus.  This 
was  only  practised  in  one  case.  He  then  made  an  incision  one  and 
a  half  inches  in  length,  commencing  at  the  root  of  the  nose  and 
extending  upward  over  the  nasal  eminence  of  the  frontal  bone  in 
the  central  line  of  the  brow.  Luc's  operation  was  similar  and  the 
method  is  sometimes  referred  to  as  the  Ogston-Luc  operation.  Lie, 
however,  employed  curettage  and  then  inserted  an  intranasal  drain. 
This  procedure  was  practised  in  London  by  ^Yaggett■^  and  others. 
This  operation  Luc  and  many  others  abandoned  for  the  operation 
of  Killian.  The  ojx'ration  of  Kuhnt,''  removing  the  front  wall 
of  the  sinus,  produced  such  deformity  that  operators  and  patients 
alike  shrank  from  the  disfigurement.  This  the  operation  of  Killian 
largely  avoided.  In  1895  he  described^  and  in  1902  he  further 
elaborated*  his  method  of  incision  through  the  eyebrow  and  pre- 
servation of  the  upper  orbital  arch  whereby  complete  exposure  of 
the  frontal  sinus  was  obtained  and  less  disfigurement  was  the 
result.  By  prolonging  the  incision  down  beyond  the  inner  angle 
of  the  orbit  a  field  of  bone  was  included  in  a  flap  turned  downward 
and  outward  which  could  be  turned  back  into  i)lace  after  curettage 
and  breaking  down  of  carious  bone  and  septa  obstructing  drainage 
in  all  the  upper  accessory  cavities  of  the  nose,  the  frontal,  the 

'  Tilley:  The  Lancet,  September  26,  1890,  II,  p.  8GG. 

*TreiteI:  Berliner  klinische  Wochenschrift,  No.  51,  1896,  XXXIII,  p.  1139. 
Botey:  Revista  di  ('iencias  Medicas  de  Barcelona,  Nos.  22-23,  1896,  XXII,  i)p. 
506,  535. 

'  Luc:  Bulletin  et  Menioires  de  la  societe  frangaise  de  laryngologie  et 
d'otologie,  1896,  XII,  p.  326. 

*  Luc:  Bulletin  de  I'acaddmie  de  medecine,  March,  2,  1897,  XXXVII,  p. 
240. 

'  Waggett:  Internat.  Centralblatt  f.  Laryngologie,  1899,  XV,  p.  140. 
^  Kuhnt:  Ucber  die  Entziindlichen  Erkrankungen  der  Stirnhohle  und   ihre 
Folgezustiinde,  Wiesbaden,  1895. 

'  Kilhan:  Heymann's  Handbuch  d.  Laryngologie,  III,  p.  1155. 

*  Krauss  and  Kilhan:  .\rchiv  fiir  Laryngologie  und  Hhinologie,  1902,  XIII, 
pp.  28,  59. 


FRONTAL  NASAL  OPERATIONS  285 

anterior  and  posterior  ethmoidal  and  the  sphenoidal  sinuses. 
Packing  the  ca^'ities  and  irrigation  practised  through  drains  left 
in  the  external  wound  could  be  carried  out.  There  can  be  no  doubt, 
that  for  the  external  operation  this  initiated  a  technique  far  superior 
to  any  hitherto  practised.  In  the  same  year  (1895)  Gussenbauer^ 
published  an  account  of  his  operation  which  consisted  in  a  tempo- 
rary resection  of  the  nasal  frame-work  in  order  to  expose  the  frontal 
ethmoidal  or  orbital  cavities.  A  curved  incision  starting  o\er 
each  eyebrow  ran  down  along  each  side  of  the  nose  and  joined  at 
the  lower  level  of  the  nasal  bones.  The  skin  and  nasal  bones  were 
turned  up  on  the  forehead  in  such  manner  as  to  expose  the  anterior 
part  of  the  ethmoidal  region  and  the  frontal  sinus.  Many  other 
external  operations  were  suggested  and  performed.  A  resimie 
of  some  of  this  work  may  be  found  in  Bosworth's  second  volume 
of  Diseases  of  the  Nose  and  Throat  in  the  chapter  on  the  External 
Operations  on  the  Nose  (1889),  which  gives  a  good  idea  of  the 
methods  prevailing  at  that  time  and  will  serve  to  indicate  the 
advances  made  in  the  development  of  the  most  rational  and 
conservative  methods  at  present  (1913)  employed.  These  were 
the  methods  which  the  operation  of  Killian  largely  displaced. 

At  the  meeting  of  the  British  ^Medical  Association  in  1899  much 
time  was  taken  up  in  the  laryngological  section  by  English,  Ameri- 
can, and  French  authors  in  the  discussion  of  frontal  and  ethmoidal 
sinus  suppuration.  Charters-Symonds,  Moure,  Luc,  Tilley  and 
Logan  Turner  contributetl  papers  of  ^•aIue.  hi  that  of  Tilley  the 
complication  of  brain  abscess  following  operation  was  given  promi- 
nence, while  Turner  reported  examinations  by  means  of  transillu- 
mination which  revealed  many  apparent  anomalies  of  the  frontal 
sinus.  While  the  operation  of  Killian  has  been  modified  in  many 
ways,  essentially  his  method  has,  until  lately,  been  the  prevailing 
practice.  In  1911  Ritter,-  Jacques,^  and  Luc*  reported  favorably 
on  the  results  of  operations  in  which  the  whole  anterior  frontal  sinus 
wall  is  preserved  and  only  the  lower  or  orbital  wall  of  the  sinus  is 
removed.  This  modification  was  adopted  chiefly  because,  exen 
with  the  preservation  of  the  orbital  arch,  the  removal  of  bone 
above  it  often  leads  to  deep  depressions,  to  fill  out  which  many 
operators  subsequently  resorted  to  the  injection  of  paraffin. 

At  the  meeting  of  the  American  Laryngological  Association  in 
1905,  there  was  a  long  and  valuable  symposium  and  general  dis- 
cussion of  sinus  disease  and  the  operations  for  its  alleviation.  In 
a  separate  paper,  however,  Ingals  reported  a  series  of  cases,  beginning 
in  1893,  in  which  he  had  treated  the  frontal  sinus  through  the  infun- 

1  Gussenbauor:    Wionor  klinische  Wochonschrift,  No  21,  1895,  VIII,  p.  377. 

*  Ritter:  ^x>rhandlung(■n  des  Vereins  dcutscher  Laryngologcn,  1911,  p.  628. 
'  Jacques:  Verhandlungen  d.  3.  Internationalcn  Laryngo-Rhinologeii  Kon- 

gresses,  1911,  I,  p.  118. 

*  Luc:  Zeitschrift  fiir  Laryngologie,  1911,  IV,  p.  273. 


286  THE  ACCESSORY  NASAL  SINUSES 

dibulum,  leaving  a  gold  tube  in  some  of  the  cases  for  continual  irri- 
gation. Casselberry  mentioned  having  employed  a  burr  to  enlarge 
the  natural  opening.  These  cases  were  selected,  for,  naturally, 
septa  in  the  frontal  sinus  would  defeat  the  drainage  and  in  some 
the  natural  opening  was  not  successfully  entered.  The  use  of  the 
unguarded  nasal  burr  being  considered  dangerous,  in  1907  and 
lOOS,  Ingals^  and  Skillern-  described  a  device  by  which  a  probe 
having  first  been  introduced  in  the  frontal  sinus  an  electric  trephine 
was  introduced  over  it  and  an  enlargement  of  the  duct  obtained 
in  such  a  manner  that  neither  the  lateral  walls  nor  the  roof  of  the 
frontal  sinus  beyond  the  probe  could  be  damaged.  Worthington^ 
also  made  use  of  this  method  and  by  1910  Ingals^  was  a})le  to  claim 
a  cure  of  the  sui)puration  in  95  per  cent,  of  the  cases  in  from  six 
weeks  to  six  months.  By  1911  this  route  of  entering  the  frontal 
sinus  had  been  used  by  many  operators.  Ingals  had  proved  the 
position  of  the  introduced  probe  by  the  use  of  the  .r-rays.  Sieur 
and  llouvillois'^  again  made  an  anatomical  study  demonstrating 
on  the  cadaver  the  possibility  of  reaching  the  frontal  sinus  by  the 
intranasal  channel.  Vacher''  who  had  previously'  advocated  the 
treatment  of  the  frontal  sinus  suppuration  by  intranasal  methods 
again  referred  to  the  subject  in  1911,  in  France,  while  in  Germany 
Halle^  using  a  protected  electrically  driven  burr  reported  ha^'ing 
operated  on  nineteen  persons  in  this  way.  A  shield  was  held  behind 
and  internal  to  the  burr  to  protect  the  orbital  plate  of  the  ethmoid. 
It  was  freely  admitted  that  these  internal  operations  on  the  frontal 
sinus  were  not  suitable  for  all  cases.  Vacher's  internal  method 
of  operating  on  the  frontal  sinus  met  with  considerable  criticism 
in  France,^  as  did  the  similar  propositions  of  Halle  in  Germany,  and 
of  Ingals  in  America;  but  there  is  no  doubt  that  in  selected  cases, 
it  has  become  the  operation  of  choice  with  many  rhinologists. 
Maxillary  Sinus  Operations. — It  is  difficult  to  observe  any  chrono- 
logical sequence  in  a  description  of  the  operations  on  the  maxillary 
sinus  in  the  period  here  dealt  with.  We  have  seen,  howe^•e^,  in  the 
eighteenth  century  the  aiitrum  had  been  frequently  opened,  usually 
but  not  always  through  the  dental  alveoli.  Krause,  Lichtwitz, 
Myles,  Onodi,  and  others  had  followed  the  lead  of  INIikulicz  in 
perforating  by  trocar  the  nasal  wall  of  the  antrum  above  or  below 

'  Ingals:  The  Laryngoscope,  April,  1907,  XVII,  p.  284;  Journal  American 
Medical  Ass'n,  May  9,  1908,  L,  p.  1502. 

2  Skillern:  The  Laryngoscope,  June,  1908,  XVIII,  p.  439. 

^  Worthington:  The  Laryngoscope,  December,  1909,  XIX,  p.  940. 

*  Ingals:  The  Laryngoscope,  February,  1910,  XX,  p.  113. 

'  Sieur  and  Kouvillois:  Revue  hebdomadaire  de  laryngologie,  d'otologie  et 
de  rhinologie,  1911,  XXXl,  Pt.  I,  p.  225. 

®  Vacher:  Bulletin  d'otologie,  rhinologie,  laryngologie,  April,  1911,  XIV, 
p.  108. 

'  Halle:  Archiv  fiir  Laryngologie  und  Rhinologie,  1911,  XXIV,  Heft  2,  p.  249. 

*  Society  frangaise  de  I'oto-rhino-laryngologie,  1911.  Ref.,  Internat.  Centr. 
f.  Laryngologie,  1912,  XXVIII,  p.  556. 


MAXILLARY  SINUS  OPERATIONS  287 

the  inferior  turbinate,  and  Ono(li,i  in  1903,  had  devised  a  trocar 
for  entering  and  dilating  the  natural  opening  in  the  middle  meatus. 
Jansen,-  after  referring  to  the  reports  of  Hartmann,^  who  in  1899 
claimed  to  have  cured  a  large  proportion  of  cases  of  antrum  sup- 
puration by  irrigation  through  the  hiatus  semilunaris,  and  to  the 
poor  results  obtained  by  methods  of  operations  which  were  really 
only  those  of  earlier  pre-rhinoscopic  authors  revived,  and  to  which 
I  have  referred  in  foreging  pages,  described  a  more  thorough  opening 
of  the  sinus  through  the  facial  wall  of  the  upper  jaw.  He  did  not 
in  this  paper  inaugurate  any  absolutely  new^  procedure,  ])ut  it  was 
the  first  of  his  publications  which  subsequently  developed  his 
method  of  attacking  the  ethmoidal  and  sphenoidal  sinuses  through 
this  avenue  of  the  maxillary  sinus.  It  also  drew  attention  more 
pressingly  to  the  fact  that  pus  in  the  antrum  owed  its  origin  often 
to  suppuration  in  the  frontal  ethmoidal  and  sphenoidal  cavities, 
and  explained  the  reasons  why  so  often  disappointment  followed 
operations  for  the  relief  of  pus  in  the  maxillary  sinus  below.  His 
proposal  to  turn  the  mucous  membrane  formerly  covering  the 
excised  bone  into  the  antrum  was  subsequently  adopted  by 
other  operators,  where  disease  or  curettage  in  the  treatment  of  it 
had  destroyed  the  antral  mucosa.  Berens,'*  in  America,  practised 
this  method  in  a  large  number  of  cases.  In  America,  in  1893, 
Caldwell'^  described  a  method  of  operating  on  the  maxillary  sinus 
which  consisted  in  opening  the  antrum  in  the  canine  fossa  and 
through  this  making  an  opening  in  the  nose.  Later  this  operation 
was  practised  by  Spicer''  in  England  and  by  Luc^  in  France,  and 
has  generally  been  known  as  the  Caldwell-Luc  operation.  Kiister 
had  in  1889  advocated  the  extensive  opening  of  the  external  bony 
walls  of  the  antrum  in  conformity  with  the  extreme  doctrines  for 
all  suppurating  ca\'ities.  Partsch^  and  Scheinmann  had  advocated 
the  use  of  a  trephine.  Others  used  the  chisel.  All  operators  used 
tampons  for  a  shorter  or  longer  time  after  operation.  Boenninghaus^ 
followed  the  technique  of  Caldwell-Luc,  but  turned  into  the 
antrum,  as  Jansen  had  recommended  for  the  mucosa  of  the  facial 
wall,  the  mucosa  of  the  nasal  chamber  covering  the  bone  piece  he 
removed,  wiiich  was  often  very  large.  Packing  the  antral  cavity 
only  he  thus  held  the  mucosa  in  place.    Luc,^"  in  1900,  published  his 

1  Onodi:  Ai-chiv  fiU-  Larynologie  und  Rhinologie,  1903,  XIV,  p.  154. 

^  Jansen:  Archiv  fiir  Laryngologie  und  Rhinologie,  1893,  I,  Heft  2,  p.  135. 

^  Hartmann:  Deutsche  medizinische  Wochenschrift,  1889,  XV,  p.  190. 

*  Berens:  The  Laryngoscope,  March,  1904,  XIV,  p.  177. 

5  Caldwell:  New  York  Medical  Journal,  November  4,  1893,  LVIII,  p.  528. 
^  Spicer:   Proceedings   British  Medical  Ass'n,   1894;  Internat.  Centralblatt 
fur  Laryngologie,  1894-5,  XI,  p.  882. 

'  Luc:  Archives  Internationales  de  laryngologie,  etc.,  No.  3,  1897,  X,  p.  273. 

*  Partsch:  Ref.  in  Boenninghaus. 

^  Boenninghaus:  Archiv  fiir  Laryngologie  und  Rhinologie,  1897,  VI,  p.  213. 
^°  Luc:  Lectures  sur  les  suppurations  de  I'oreille  nioj^enne  et  des  cavites 
accessoires  du  nez  et  sur  leurs  complications  intracraniennes,  Paris,  1900. 


288  THE  ACCESSORY  NASAL  SINUSES 

lectures  on  supiJiiratioii  in  the  accessory  sinuses  of  tlie  nose  which 
is  a  fair  representation  of  the  best  work  in  France  at  the  time. 
All  operators  on  the  maxillary  sinus  met  defeat  in  their  results 
owino;  to  the  prompt  closure  of  any  opening  made  through  the  bony 
walls,  unless  an  obturator  was  worn  as  in  the  old  Cowper  operation 
and  the  later  Jansen  operation  above  referred  to.'  The  perforation 
would  not  remain  open  until  the  discharge  ceased.  To  avert  this 
and  avoid  the  irritation  of  an  obturator  or  a  metal  tube  drain,  the 
Caldwell-Luc  operation  was  extended  by  some  operators  to  the 
complete  removal  of  the  naso-antral  wall,  making  one  large  cavity 
out  of  the  antrum  and  the  inferior  and  middle  nasal  meatus.  Alsen- 
and  (Jerber,  in  1901,  carried  out  this  method.  Denker/  in  1905, 
extended  the  technique  of  Luc  in  such  a  way  that  the  entire  inner 
bony  wall  of  the  maxillary  antrum  was  removed  and  the  mucous 
membrane  of  its  nasal  surface  })reserved  so  that  by  means  of  a 
tanij)on  it  could  be  made  to  line  the  denuded  bony  floor  of  the 
antrum.  He  adopted  some  of  the  technique  of  Jansen,  of  Kretsch- 
mann,^  Boenninghaus  and  Friedrich.'^  Freer''  and  others  have 
succeeded  in  removing  the  greater  part  of  the  inner  wall  of  the 
antrum  including  the  inferior  turbinated  bone  by  intranasal  opera- 
tion, thus  accomplishing  the  object  the  Caldwell-Luc  operation  was 
designed  to  attain.  While  its  possibility  was  demonstrated,  this 
diflicult  operation  has  not  found  favor  in  competition  with  the 
procedure  of  Luc  until  recently,  but  in  the  last  two  or  three  years 
this  method  has  been  largely  practised.^  Whether  by  the  extensive 
operation  of  Denker  or  by  that  of  Freer  and  others  the  whole  naso- 
antral  wall  with  the  inferior  turbinate  or  a  larg(>  part  of  these 
structures  was  removed,  it  was  soon  found  that  the  walls  of  this 
cavity  became  encrusted  with  dried  secretions  and  continual 
irrigation  was  necessary  for  years.  This  was  another  reason  for  the 
use  of  a  more  rational  surgical  treatment  of  sinus  disease,  (iradu- 
ally  the  object  to  be  attained  was  seen  to  be  to  locate  the  bony 
cell  or  cells  in  the  upper  nasal  labyrinth  which  was  the  origin  of 
the  pus  in  the  lower  meatus  and  in  the  antrum  itself;  to  establish  a 
drainage  by  removal  of  the  lower  bony  wall  or  the  obstructing  soft 
parts.     Jansen  sought  to  accomplish  this  through  the  antrum  by 

1  See  also,  Herzfeld:  Monatsschrift  fiir  Olironhoilkunde,  No.  1,  1898, 
XXXII,  p.  2.5.  Port:  MUnclicnor  nicdizinische  Wochensfhrift,  No.  39,  1898, 
XLV,  p.  12.58. 

2  Alsen:  Archiv  fiir  Laryngologie  und  Rhinologie,  1901,  XII,  i).  227. 

'  Donker:  Archiv  fiir  Larj^ngologie  und  Rhinologie,  190,5,  XVII,  p.  49. 

*  Kretschmann:  Miinchcner  mcdizinische  Wochenschrift,  No.  1,  1905,  LII, 
p.  20;  No.  26,  1907,  LIV,  p.  127.5. 

*  Friedrich:  Deutsche  niedizinischc  Wochenschrift,  No.  37,  1904,  XXX,  p. 
1337.    Borger:  Archiv  fiir  Laryngologie  und  Rhinologie,  190(5,  XVIII,  p.  ,524. 

"  Freer:  The  Laryngoscope,  May,  1905,  XV,  p.  343. 

'  P^or  evidence  of  the  tendency  to  operate  on  the  maxillary  sinus  by  tiic  intra- 
nasal route  see  references  to  articles  on  p.  130-131  of  Scmon's  Internat.  Central- 
blatt  fiir  Laryngologie  und  Khinologie,  1910,  Vol.  XXVI. 


MAXILLARY  SINUS  OPERATIONS  289 

scraping  away  the  ethmoidal-cell  wall  at  the  upper  part  and  the 
sphenoid-sinus  wall  at  the  upper  and  posterior  angle  of  the  antrum. 
The  technical  difficulties  were  great  and  the  results  in  the  hands 
of  other  operators  were  not  brilliant.  Cases  were  constantly  being 
reported  in  which  the  sphenoidal  sinus  was  opened  through  the 
nose,  curetted,  drainage  established,  and  the  case  cured  without 
the  extensiA'e  and  difficult  technique  of  Jansen,  as  for  instance  in 
the  report  of  Flatau.^  For  the  ethmoidal  and  sphenoidal  cells 
this,  chiefly  through  the  demonstrations  of  Hajek,-  has  finally 
become  in  more  recent  years  the  operation  of  choice.  To  obviate 
the  drawbacks  which  the  experience  of  years  has  demonstrated 
in  the  results  of  creating  these  large  cavities  they  have  been  much 
limited  of  late.  Hirsch,''  in  1911,  described  an  operation  whereby  he 
sought  to  overcome  the  evil  effects  of  the  destruction  of  the  inner 
wall  of  the  maxillary  sinus  in  those  operations  on  it  where  the  nasal 
chambers  are  made  to  communicate  widely  and  permanently  with 
it.  The  inferior  turbinate  was  temporarily  resected,  a  wide  opening 
established  beneath  it,  and  then  it  was  fastened  again  in  place. 
Still  more  formidable  operations  grew  out  of  the  procedure  of 
Rouge."*  In  1873  he  had  suggested  an  operation  consisting  of  an 
incision  beneath  the  upper  lip  and  a  separation  of  the  septal 
cartilage  from  its  articulation  with  the  superior  maxillary  bones, 
thus  gaining  larger  access  to  the  interior  of  the  nose  than  could  be 
obtained  through  the  natural  opening.  Later  this  technique  was 
supplemented  by  the  procedure  of  Partsch-^  and  Loewe,^  which  con- 
sisted further  in  a  severance  of  the  whole  septum  and  of  the  outer 
and  inner,  and  anterior  and  posterior  walls  of  each  antrum  from 
the  palatal  arch,  so  that  the  whole  of  the  latter  could  be  rlepressed 
on  the  tongue  and  a  much  larger  access  thus  obtained  to  all  the 
sinuses,  but  especially  to  the  sphenoid  region  and  the  posterior 
ethmoidal  cells  chiefly  designed  to  facilitate  the  removal  of  post- 
nasal tumors.  The  hemorrhages  occurring  in  these  formidable 
procedures  prevented  their  general  adoption,  though  they  have 
occasionally  been  reported.  Bardenhauer's  modification  of  the 
Rouge  operation  in  1898  consisted  chiefly  in  a  very  much  wider 
separation  of  the  soft  parts  from  the  anterior  surfaces  of  the  bones 
of  the  face  and  even  the  dislocation  of  the  nasal  bones  to  gain  free 
access  to  the  frontal  sinuses  as  well  as  to  the  maxillary  and  ethmoid. 
Goris"  in  France  was  an  advocate  of  this  technique  and  for  a  number 

1  Flatau:  Berliner  klin.  AVochensch.,  1S94,  XXXI,  p.  791. 

-  Hajek:  Archiv  fur  Larvngoloffic  uiul  Rhinologie,  1S9(),  IV',  p.  277. 

3  Hirsch:  Monatsschrift  Rir  Ohrenheilkun(ie,  1911,  Heft  6,  XLV,  p.  637.  ^ 

■*  Rouge:  Xouvello  mothode  rhirurgicale  pour  le  traitemont  de  I'ozene,  1873. 

*  Partsch:  Verhandlungen  der  deutschen  Gesellschaft  fiir  Chirurgie,  1898, 
XXVIl,  p.  552. 

^  Lopwe:  Monatsschrift  fiir  Ohrcnheilkunde,  July-October,  1900,  XXXIV, 
pp.  259,  37(1. 

'  Goris:  International  Medical  Congres.s,  1900,  Larvngological  Section,  p. 
101. 

19 


290  THE  ACCESSORY  NASAL  SINUSES 

of  years  was  active  in  the  performance  of  many  serious  opcTations 
about  the  nose  and  its  sinuses.  Moure,'  in  ISUC),  drew  attention  to 
l)urulent  infections  of  the  maxillary  sinus  in  children  as  having 
some  relation  to  the  eruption  of  the  teeth  at  a  time  when  the  sinus 
had  become  completely  developed,  but  d'Arcy  Power,^  1897,  claimed 
to  have  observed  maxillary  sinus  empyema  in  a  child  only  eight 
weeks  old.  ]\layer,''  1901,  reported  a  case  in  a  child,  aged  two  and 
a  half  years.  Coffin^  in  reporting  four  cases  alluded  to  suppuration 
in  the  maxillary  sinus  operated  on  when  the  child  was  six  months 
old.  I  have  referred  to  the  recent  work  of  Haike,  Onodi,  and  of 
Canestro  on  sujipuration  of  the  accessory  sinuses  in  children 
(pp.  279-281),  the  latter  reporting  a  case  in  a  child  twenty-six 
days  old. 

Ethmoid  Cells. — The  claim  of  Schadlc^  that  affections  of  the 
maxillary  sinus  are  often  a  factor  in  the  etiology  of  hay  fever  has 
received  no  confirmation  or  recognition.  These  reflexes  had  been 
noticed  by  Bosworth*^  as  due  to  ethmoid  disease.  His  enthusiasm 
for  intranasal  operation  in  the  eradication  of  nasal  polypi  and  their 
bony  attachments  in  the  ethmoid  accomplished  much  in  arousing 
interest  in  ethmoidal  disease  in  America,  though  his  contention 
that  the  latter  is  a  primal  factor  in  the  etiology  of  asthma  and 
hay  fever  has  not  received  the  support  of  his  colleagues  as  a  rule. 
Everywhere,  in  intranasal  operations  on  the  ethmoid,  removal  of 
the  middle  turbinate,  in  whole  or  in  part,  and  often  of  the  lower 
turbinate,  was  a  prelude  to  the  various  surgical  attacks  on  the 
ethmoidal  cells  and  the  improvement  in  the  surgical  armamentarium 
for  this  j)urpose  has  been  very  great.  Griinwald^  devised  a  number 
of  curettes,  chisels,  and  rongeurs  by  means  of  which  access  to  and 
treatment  of  the  accessory  sinuses  were  greatly  facilitated.  These 
are  set  forth  in  his  text-book  and  in  many  previous  communications 
on  intranasal  surgery.  Hajek  (1.  c),  publishing  his  first  edition  in 
1899,  has  of  late  years  (1899-1909)  unquestionably  been  the  most 
influential  writer  in  developing  the  technique  and  in  insisting  on 
the  intranasal  route  for  operations  on  the  ethmoid  cells.  The 
operations  of  Jansen,  of  Killian,  of  Rouge  with  their  innumerable 
modifications  represent  the  ojjerative  technique  in  reaching  the 
ethmoid  by  the  extranasal  route,  but  involving,  as  thev  do,  the 
preliminary  invasion  of  the  frontal  or  maxillary  sinuses,  they  have 

'  Moure:  lievuo  hobdomadairo  do  laryngologic,  d'otologie  et  dc  rhinologie, 
No.  43,  October  24,  1896,  XVI,  p.  12(55. 

2  d'Arcy  Power:  British  Medical  Journal,  September  25  and  November  6, 
1897,  II,  pp.  808,  1337. 

^  Mayer:  Transactions  American  Laryngological  Ass'n,  1901,  p.  54. 

*  Coffin:  The  Laryngoscope,  November,  1904,  XIV,  p.  881. 

6  Schadlc:  Medical  Record,  May  25,  1907,  LXXI,  p.  941. 

«  Bosworth:  Medical  Record,  October  13,  1894,  XLVI,  p.  457. 

^  Griinwald:  Lehre  von  den  Naseneiterungen,  IMiinchen,  1893.  Verhandl.  d. 
Gesellschaft  deutscher  Naturforscher,  1896,  2  th.,  2  Hillfte,  p.  406.  Central- 
blatt  fur  Chirurgie,  No.  3,  19G6,  XXXIII,  p.  84. 


SPHENOID  SINUS  AND   THE  HYPOPHYSIS  291 

been  for  the  most  part  practised  in  cases  in  which  these  cavities 
were  themselves  affected.  x\s  intranasal  metliods  have  with  increas- 
ing frequency  been  applied  to  these,  the  ethmoid  technique,  as 
developed  by  Hajek  and  others,  has  come  more  and  more  into 
vogue.  Uffenorde/  in  1907,  wrote  a  monograph  on  the  affections  of 
the  ethmoid  cells,  advocating  the  external  in  preference  to  the 
internal  methods  of  operating,  but  the  drift  has  been  away  from 
this  advice  for  a  number  of  years. 

Sphenoid  Sinus  and  the  Hypophysis. — Clearing  away  the  ethmoidal 
labyrinth,  either  by  intranasal  operation  or  by  the  way  of  the  antrum 
or  frontal  sinus,  is  naturally  followed  by  the  exposure  of  the  sphe- 
noidal. We  have  noted  the  relationship  which  Onodi  showed  to  exist 
between  the  posterior  ethmoidal  cells  and  the  sphenoidal  cavity. 
While  this  is  fairly  brought  out  in  the  earlier  work  of  Zuckerkandl 
it  was  studied  later  much  more  in  detail  in  connection  with  the 
operations  on  these  cavities  not  only  to  evacuate  their  contents 
but  to  furnish  a  route  to  operations  on  the  hypophysis  cerebri 
recently  undertaken.  The  very  great  interest  excited  in  the  phe- 
nomena presented,  physiologically  and  pathologically,  by  the 
ductless  gland  inevital)ly  led  to  the  development  of  surgical  attacks 
on  the  hypophysis.  The  way  of  reaching  the  sphenoidal  sinuses 
through  the  nose  had  already  been  pointed  out  in  the  works  of 
Zuckerkandl,  Killian,  Tilley,  Coakley,  Griinwald,  Jansen,  and  others 
to  whom  I  have  referred.  These  are  reviewed  with  the  writings 
of  others  by  Skillern.-  In  1906  Horsley^  had  reported  his  method 
of  making  externally  a  lateral  incision  and  lifting  the  middle 
cerebral  lobe  and  thereby  reaching  the  pineal  gland  without  entering 
the  nasal  cavities.  Caton  and  Paul,^  in  1893,  had  first  proposed 
this  method.  ]\Ioszkowitz,^  Schmiegelow,'^  Hirsch,^  Goris,*  and  West^ 
operated  through  the  nose,  the  latter  as  well  as  Skillern  giving  a 
good  bibliography  of  the  subject.  Loewe^"  and  A'orschiitz,''  operating 
bv  the  Partsch  method,  extended  it  in  such  a  wav  as  to  include 
"decortication  of  the  face,"  i.  e.,  removing  from  the  soft  parts, 
after  reflecting  them  upward,  the  facial  and  nasal  wall  of  the 
antrum  and  the  ascending  ramus  of  the  superior  maxilla.  Kiihn^^ 
in  1911  proposed  to  reach  the  sphenoid  sinus  and  through  it  the 
hypophysis  by  way  of   the  mouth,  chiseling   some   of  the   hard 

^  Uffenorde:  Die  Erkrankungen  des  Siebbeins,  Jena,  1907. 

2  Skillern:  Archiv  flir  Laryngologie  und  Rhinologic,  1908,  XX,  p.  415. 

3  Horsley:  British  Medical  Journal,  1906,  II,  p.  411. 

*  Caton  and  Paul:  British  Medical  Journal,  1893,  II,  p.  1421. 

5  Moszkowitz:  Wiener  klinische  Wochenschrift,  1907,  XX,  p.  792. 

6  Schmiegelow:  Ref.,  Internal.  Centralblatt  fiir  Laryngologie,  1911,  XXVII, 
p.  117. 

'  Hirsch:  Wiener  khnische  Wochenschrift,  No.  44,  1910,  XXIII,  p.  1578. 

»Goris:  Ref.,  Centralblatt  fiir  Laryngologie,  1911,  XXVII,  p.  118. 

'  W'est:  Archiv  fiir  Laryngologie  und  Rhinologie,  1910,  XXIII,  p.  288. 
'"  Loewe:  Berliner  klinische  Wochenschrift,  1908,  XLV,  p.  378. 
"  Vorschiitz:  Deutsche  Zeitschrift  fiir  Chirurgie,  1909,  XCIV,  p.  G16. 
12  Kiihn:  Berliner  klin.  Wochensch.,  1911,  XLVIII,  p.  914. 


292  THE  ACCESSORY  NASAL  SINUSES 

palate,  some  of  the  vomer  and  the  ptervfjoid  process,  and  carrying 
the  soft  palate  with  them  l)ackward  in  the  pharynx.  These  were 
to  he  stitched  l:)ack  in  phice  after  the  evacnation  of  the  sphenoid. 
Hypophyseal  surgery  was  discussed  in  1911  at  the  meeting  of  the 
American  Laryngological  Association,  and  Onodi^  made  some  very 
interesting  remarks  on  the  subject  elsewhere. 

Complications  of  Accessory  Sinus  Disease. — It  remains  to  say  a 
few  words  on  the  coniplications  of  accessory  sinus  flisease  which 
were  reported  from  time  to  time  as  they  had  an  important  influence 
on  the  development  of  the  diagnosis  and  operative  therapy.  They 
were  chiefly  those  of  the  contents  of  the  neighboring  cavities  of 
the  orbit  and  the  cranium.  In  1870  Hermann  Knapp-  reported 
a  case  of  orbital  abscess  involving  the  anterior  ethmoidal  cells, 
in  which  apparently  the  trouble  originated.  Subsequently  this 
author  made  many  contributions  to  the  same  subject,''  reporting 
in  1880  the  invasion  of  the  orbit  from  an  empyema  of  the  frontal 
sinus.  Others  also  noted  such  cases^  before  the  publication  of 
Ziem's  paper.  In  1893  Ziem''  drew  attention  to  the  intimate 
coiniection  between  orbital  and  ocular  lesions  and  disease  of  the 
up])er  accessory  sinuses.  These  observations,  though  forgotten  for 
many  years,  have  of  late  been  expanded  by  the  published  experiences 
of  others,  especially  by  the  Aaluable  anatomical  work  of  Onodi.^ 
Shortly  after  the  appearance  of  Ziem's  article,  Kuhnt  (1.  c),  from 
the  stand-point  of  the  ophthalmologist,  studied  the  affections  of 
the  frontal  sinus  in  their  relation  to  eye  disease.  In  France  it 
was  treated  by  Hohmer.^  Axenfeld,*^  in  1902,  wrote  of  the  orbital 
complications  of  disease  of  the  frontal  and  ethmoidal  sinuses. 
After  four  or  five  years  the  nimiber  of  articles  and  treatises  on  the 
relationship  between  accessory  nasal  sinus  disease  and  ocular  orbital 
and  optic  ner\e  afl'ections  was  very  largc.^  A  large  number  of 
reports  of  ocular  and  orbital  complications  was  made  in  1911."^ 

^  Onodi:  Zeitsehrift  fur  Tjaryngologic,  1911,  IV,  p.  1. 

^  Knapp:  Trans.  Fifth  Oplithalmological  Congress,  1876,  p.  57. 

^  Knapp:  Archives  of  Oi)hthahnology,  ISSO,  IX,  No.  2,  p.  185. 

■•  For  instance,  Peltesohn:  Centralblatt  fiir  praktische  Augenheilkunde, 
February,  1888,  XII,  p.  35. 

'■>  Ziem:  Monatsschrift  fur  Ohrenlieilkunde,  etc.,  No.  8-9,  1893,  XXVII,  pp. 
231,  2t)l. 

^  Onodi:  Die  Sehnerven  und  die  Ncbenlu'ihk^n  der  Nasc,  Wien,  1907. 

'  Rohmer:  Revue  ni6dicale  de  Test,  July  1,  1S95,  XXV^II,  p.  385. 

8  Axenfeld:  Deutsche  medizinische  Wochenschrift,  No.  40,  1902,  XXVIII, 
p.  713. 

'  Schmiegelow:  Archiv  fiir  Laryngologie  und  Rhinologie,  1906,  XVIII, 
Heft  3,  p.  478.  Posey:  Jour,  of  I'^ye,  I'^ar  and  Throat  Diseases,  1905,  X,  p.  31. 
N.  Y.  Medical  Journal,  March  2,  1907,  LXXXV,  p.  404;  and  November  2, 
1907.  Onodi:  Transactions  British  Mcflical  Association,  July,  1904.  Archiv 
ftir  Laryngologie  "und  Rhinologie,  1905,  XVII,  p.  260.  Baumgarton:  Monats- 
schiift  fiir  Ohrenheilkunde,  etc.,  No.  5,  1906,  XL,  p.  303.  Hoffmann:  Zeit- 
schrift  fiir  Augenheilkunde,  etc.,  1906,  XVI,  (Kuhntfest.),  p.  1.  Logan  Turner: 
Edinburgh  Medical  Journal,  May,  1909,  n.  s.,  II,  p.  423. 

'"  See:  Internal.  Centralblatt  fur  Laryngologie,  etc.,  1911,  XXVII,  pp.  402-.3- 
4-5. 


TREND  TO  CONSERVATISM  IN  OPERATION  293 

As  early  as  1895  Dreyfiiss^  could  collect  reports  of  many  cases 
of  cerebral  disease  resulting  from  suppuration  in  the  nasal  sinuses, 
twenty-two  being  due  to  frontal  sinus  disease,  the  posterior  wall 
of  the  frontal  sinus  being  perforated  in  many  of  them  by  an  osteitis. 
It  has  since  been  more  fully  recognized  how  apt  the  inflammation 
of  the  soft  parts  is  to  spread  to  the  bony  walls.  Craig,'-  in  1900, 
published  a  collection  of  cases  from  literature  of  this  nature,  though 
he  seemed  to  find  reason  to  believe  that  maxillary  antrum  suppura- 
tion was  more  commonly  the  starting-point  for  cerebral  inflamma- 
tion than  that  of  the  frontal,  a  view  which  other  investigators 
have  for  the  most  part  not  supported.  St.  Clair  Thompson^  also 
wrote  on  the  subject.  Onodi,*  in  1911,  collected  statistics  in  106 
cases  in  which  cerebral  abscess  had  occurred  as  a  comjilication  of 
accessorv  sinus  disease  and  in  these  106  cases  the  frontal  sinus  was 
involved  in  82,  the  ethmoid  in  11,  the  maxillary  sinus  in  4  cases, 
and  the  sphenoid  in  1.  It  was  recognized  that  an  osteitis  was  apt 
to  accompany  the  affections  of  frontal  sinus  and  the  complications 
which  experience  revealed  in  these  cases  seemed  an  indication  for 
operation  in  every  case  of  frontal  sinusitis  to  some  authors.  To 
others  it  seemed  that  these  operations  themselves  were  in  many 
cases  apt  to  precipitate  rather  than  to  avoid  the  dangers  arising 
from  them.  In  Gerber's  book^  we  find  an  example  of  the  former 
view,  while  in  Kuttner's  review^  of  it  we  find  set  forth  the  con- 
servative opinion  which  seems  likely  to  prevail  in  the  future. 

Trend  to  Conservatism  in  Operation. — Weil,^  in  1896,  not  only 
expressed  the  opinion  that  nearly  all  inflammatory  affections  of 
an  acute  nature  tended  to  spontaneous  recovery  but  that  these 
as  well  as  the  chronic  cases  were  due  to  an  extension  from  acute 
inflammatory  conditions  of  the  nasal  mucosa.  He  and  many  who 
took  part  in  the  discussion  of  his  paper  at  this  time  in  A'ienna 
expressed  a  preference  for  treating  maxillary  sinus  disease  through 
the  nasal  orifice  of  the  antrum,  or  through  some  enlargement  of 
it.  The  difficulty  and  in  many  cases  the  impossibility  of  this 
technique  subsequently  became  evident,  but  in  Vienna  operative 
procedures  on  the  accessory  sinuses,  have  always  been  markedly 
under  the  influence  of  Hajek's  sane  and  painstaking  methods. 
Many  points  in  the  experience  hitherto  gained  came  out  in  the 
discussion  on  accessory  sinus  disease  at  the  International  Medical 

1  Dreyf uss :  Die  Krankhciten  dcs  Gehirns  unci  soiner  adnexa  im  Gefolge  von 
Xaseneitenmgen,  J(>na,  1S96. 

2  Craig:  New  York  Medical  Journal,  March  24,  1900,  LXXI,  p.  420. 

3  St.  Clair  Thompson:  The  Lancet,  August  12,  1905,  II,  p.  431. 

•*  Onodi:  Rcf.,  Internat.  Centralblatt  fiir  Larvngologie,  etc.,  1911,  XXVII,  p. 
433. 

^  Gerber:  Die  CompUcationen  der  Stirnhohlenentziindungen,  Berlin,  1909. 

6  Kuttner:  Internat.  Centralblatt  fiir  Larvngologie,  etc.,  1909,  p.  IGS. 

'  Weil:  Wiener  medizinische  Wochensclu-ift,  Nos.  16-20,  1897,  XLVII,  pp. 
705,  762,  814,  866,  910. 


294  THE  ACCESSORY  NASAL  SINUSES 

Congress  at  London  in  1897.    In  the  same  year  a  similar  discussion 
followetl  the  presentation  of  a  case  by  Bryan  at  the  meeting  of  tlie 
American  Laryngological  Association.     Killian^  recommended  in 
1909  a  method  of  treatment  of  acute  accessory  sinus  disease  by  the 
appHcation  of  heat  and  Hght  furnished  by  an  air-tight  box  suppUed 
with  electric  lights  of  high  candle  power,  a  sort  of  sweat  box  supple- 
mented by  high  intensity  light,  invented  by  Brimings.    This  was 
said  to  relieve  the  j)ain  and  promote  the  fiow  of  secretion  and  hasten 
the  natural  process  of  cure.    At  this  meeting  he  and  others  expressed 
opinions  favorable  to  a  more  conservative  attitude  in  questions 
of  operative  procedure,  but  long  before  this  it  had  become  evident 
to  conservati^'e  men  that  the  enthusiasm  for  extensive  and  destruc- 
tive operations  on  the  accessory  sinuses  was  being  carried  to  a 
dangerous  extreme.    In  1901  Sir  Felix  Semon-  warned  his  confreres 
against  this  tendency  in  England.    A  similar  protest^  in  America  in 
1905  w^as  the  consequence  of  this  continued  lack  of  critical  differ- 
entiation in  the  selection  of  cases  for  operation.     Shortly  after 
this  there  were  signs  of  a  more  rational  judgment  beginning  to  be 
brought  to  bear  on  the  subject.     Kuttner^  on  many  occasions 
maintained  the  same  conservative  ground  in  Germany.     Hajek's* 
conservative  stand  in  1909  in  Vienna  in  regard  to  the  treatment  of 
accessory  sinus  suppuration  is  a  further  instance  of  the  rational 
position  which  has  finally,  after  twenty  years,  been  established 
among  laryngologists.    Taken  together  with  Semon's  early  and  wise 
words  in  London  and  Kuttner's  in  Berlin  it  is  especially  strengthened 
by  the  general  tone  of  moderation  which  has  found  its  way  into 
most  if  not  all  of  the  recent  works  on  the  subject.    At  the  Inter- 
national   Congress    in    1909    much    of   the   time   was   taken    up 
with    the    discussion    of    this    aspect    of    the    subject   and   with 
the  significant  frequency  of  cerebral  complications  in   accessory 
sinus  troubles  which  had  been  treated  surgically.    An  interesting 
discussion    of    the    subject   took    place    at   the    meeting    of    the 
American  Laryngological  Association  as  early  as  1903.     For  the 
ten  years  pre\ious  to  this  it  had  been  often  urged  that  the  nasal 
sinus  affections  could  be  traced  in  their  origin  to  inflammation 
within  the  nasal  chambers.    This  was  emphasized  and  the  remark 
was  made  by  Freeman  that  the  sinus  affection  was  nearly  always, 
when  unilateral,  on  the  side  of  the  nose  presenting  in  the  meatus 
the  greatest  amount  of  obstruction.     It  was  not  until  the  resort 
to  intranasal  operation  in  opening  the  sinuses  became  more  common 
that  the  necessity  was  felt  for  correcting  these  intranasal  causes 

'  Killian:  International  Medical  Congress,  1909,  Ref.,  Semon's  Internat. 
Centralblatt  f.  Larynp;ologie,  1910,  XXVI,  p.  425. 

^  Semon:  Journal  of  Laryngology,  1901,  XVI,  p.  199. 

3  Wright:  N.  Y.  Medical  Journa'l,  October  7,  1905,  LXXXII,  p.  7G0. 

*  Kuttner:  Berliner  klinischc  Wochenschrift,  No.  11,  1908,  XLV,  p.  529. 

^  Hajek:  16  Congres  International  de  Medceine,  Compte  Rendu,  1909,  XV, 
(Laryngologie),  p.  177. 


LOCAL  ANESTHESIA  IN  SINUS  OPERATIONS  295 

of  sinus  disease.  This  has  grown  into  a  weighty  argument  against 
the  external  operation,  when  it  is  possible  to  avoid  it.  While  there 
has  been  reason  to  suppose  that  many  of  the  cases  with  meningeal 
symptoms  as  a  result  of  accessory  sinus  disease,  reported  occasion- 
ally as  cured  after  operation  on  the  nasal  cavity,  were  really  cases 
with  cerebral  symptoms  of  septicjemia,  there  are  some  reports  in 
which  the  evidence  of  an  actual  purulent  meningitis  once  existing  yet 
later  cured  is  very  strong.^  There  still  seems  good  reason  to  suppose 
that  in  the  vast  majority  of  the  cases  such  a  fortunate  result  does 
not  obtain,  except  in  the  event  of  a  cerebral  abscess  opportunely 
detected  and  drained  through  an  opening  in  the  walls  of  the  sinuses. 
As  an  example  of  the  extent  to  which  radical  operations  were 
advocated  for  accesso^^'  sinus  disease  bv  some  writers  one  mav  cite 
the  brochure  of  Ufi'enorde,-  published  in  1907,  shortly  after  the 
movement  in  criticism  of  operative  radicalism  had  gained  headway. 
His  declaration  that  every  conservative  method  was  fruitless, 
even  harmful,  was  promptly  criticised.  Since  about  this  date  there 
can  be  clearly  recognized  a  general  tendency  among  rhinologists 
to  adopt  those  methods,  the  technique  of  which  has  been  greatly 
advanced,  by  which  openings  are  made  from  the  nasal  chambers 
not  only  into  the  Antrum  of  Highmore  and  the  sphenoidal  and 
ethmoidal  cells,  but  into  the  frontal  sinuses  as  well.  Not  a 
little  of  this  change  of  method  as  well  as  the  chief  element  in  the 
drift  toward  more  conser\atism  was  due  to  experience  with 
results  of  the  more  thorough  of  the  external  operations.  Secretion 
of  pus  was  found  to  persist  in  a  very  large  number  of  cases  and 
though  other  symptoms,  especially  pain,  were  often  relieved,  dan- 
gerous and  widely  mutilating  operations  began  to  seem  hardly 
justified  in  a  class  of  cases,  eagerly  accepted  at  first  as  suitable  for 
operation.  It  was  realized  then  that  the  imperfect  results  attendant 
on  less  radical  methods  at  first  were  not  always  due  to  conservatism. 
With  the  improved  intranasal  technique,  there  was  less  cause  for 
criticism  as  to  imperfect  drainage  being  secured.  That  there  is 
still  a  respectable  number  of  cases  in  which  the  Caldwell-Luc, 
the  Killian  and  the  Jansen  operations  are  considered  justifietl  is 
almost  universally  recognized. 

As  this  work  goes  to  press,  the  volume  of  Ross  Hull  Skillern 
on  "The  Catarrhal  and  Suppurative  Disease  of  the  Accessory  Sinuses 
of  the  Nose"  (1913)  comes  to  hand.  The  richness  in  details,  and 
especially  in  illustration,  and  its  fulness  in  historical  data  at  once 
attract  attention,  l)ut  it  came  too  late  for  careful  examination. 

Local  Anaesthesia  in  Sinus  Operations. — While  cocaine  was  at 
first  used  for  intranasal  operations  only,  from  time  to  time  pro- 
positions have  been  made  to  operate  externally  on  the  accessory 
sinuses  under  local  anaesthesia. 

1  For  instance:  Kander:  INIedizinische  Klinik,  No.  29,  1907,  III,  p.  862. 

2  Uffenorde:  Die  Erkrankungen  des  Siebbeins,  Jena,  1907. 


29G  BACTERIOLOGY  OF  THE  NOSE  AND   THROAT 

Braun,'  in  1903,  having;  cocainized  the  superior  laryn<2;eal  nerve 
by  injecting  a  solution  of  the  drug  in  its  trunk  in  order  to  obtain 
anivsthesia  in  the  curettage  of  the  hirynx,  a  procedure  which  lias 
subsequently  been  used  to  relieve  the  pain  of  laryngeal  phthisis 
on  deglutition,  Munch-  applied  the  operation  to  the  regional  ana?s- 
thesia  of  the  trigeminus  nerve  in  the  surgery  of  the  maxillary  sinus. 
13raun,^  in  1911,  introduced  this  into  Germany.  Killian,^  in  1912, 
spoke  Avell  of  it  when  applied  to  the  Gasserian  ganglion.  Such  a 
radical  operator  as  Uffenorde"  was  a  convert  to  this  method. 

Vaccines. — As  in  other  suppurative  processes  the  introduction 
of  vaccines,  due  to  the  observations  and  therapeutic  claims  of  Sir 
Almoth  Wright,  may  be  noted  at  this  time  (1910)  in  the  therapy 
of  the  accessorv  sinuses.^ 


BACTERIOLOGY  OF  THE  NOSE  AND  THROAT. 

As  in  every  other  department  of  medicine,  the  sudden  develop- 
ment of  bacteriology  had  its  efl'ect  upon  the  study  of  diseases  of 
the  upper  air  passages.  Perhaps  the  effect  was  not  so  profound, 
because  it  soon  became  apparent  that  neither  was  there  that 
urgent  need  nor  was  there  a  possibility  of  applying  to  the  nose  the 
rigid  practises  of  antisepsis. 

We  cannot  here,  as  we  have  in  many  other  questions,  so  profitably 
pass  in  review  the  history  of  our  knowledge  of  bacteria.  It  began 
in  1675  with  the  first  impro\-ement  in  magnif\'ing  glasses  by 
Leuwenhoek.  It  includes  the  interesting  story  of  what  is  called 
the  fallacy  of  spontaneous  generation.  Attacked  time  and  again, 
first  bv  lledi  in  1668,  and  bv  A'allisneri  before  the  discoverv  of 
infusoria  by  Leuwenhoek,  and  afterward  by  Spallanzani  in  1777, 
\  irchow  with  his  "Omnis  cellula  e  cellula,"  and  Pasteur  and 
Tyndall  have  destroyed  spontaneous  generation  in  our  day,  but 
further  discoveries,  reaching  back  toward  the  great  First  Cause, 
will  surely  start  it  again,  for  our  minds  cannot  be  freed  from 
the  idea  that  there  must  be  a  time  now,  just  as  man  has  always 
believed  there  was  once  in  the  past  time,  when  what  we  call 
the  animate  was  incori)orated  de  novo  with  the  inanimate. 
Since  the  first  edition  of  this  book  the  question  of  abiogenesis, 
or  spontaneous  generation,  has  come  more  and   more   near  the 

^  Braun:  Archiv  fur  klinische  Chirurgic,  1903,  LXXI,  p.  179. 

^  Munch:  Bulletins  et  nicrnoirps  dv.  la  soci6te  frangaise  d'oto-rhino-laryn- 
gologie,  May,  1909,  XXV,  Pt.  2,  ]>.  4()7. 

'  Braun:  Deutsche  Zeitschrift  fiir  Chirurgie,  1911,  CXI,  Heft  4-6,  p.  321. 
Lange:  Beitriige  zur  Anatomic,  Physiologie,  Pathologic  und  Therapie  des 
Ohres,  der  Nase  und  des  liaises,  1911,  V,  p.  294. 

Mvillian:  Internat.  Centralblatt  fiir  Laryngologic,  etc.,  1912,  XXVIII,  p. 
436. 

*  Uffenorde:  Internat.  Centralblatt  fiir  Laryngologic,  etc.,  1912,  XXVIII, 
p.  447. 

«  Brawly:  The  Laryngoscope,  September,  1910,  XX,  p.  877. 


MYCOSES  PHARYNGIS  297 

borderland  of  scientific  investigation  as  it  has  gradually  again 
established  a  more  respectable  place  for  itself  in  the  domains  of 
theory. 

The  idea  of  the  microbian  origin  of  disease  doubtless  started 
as  soon  as  the  existence  of  infusoria  was  generally  known,  so 
eager  has  always  been  the  search  for  etiology  in  medicine.  Indeed, 
the  following  reference  is  in  itself  ample  proof  of  it:  "In  1721 
the  pest  broke  out  at  JNIarseilles  and  in  the  south  of  France.  Antre- 
chau  attributed  the  contagious  principle  to  infusorial  animalcules." 
(Spr.  V.  504.)  However  interesting  it  would  be  to  follow  the  growth 
of  the  idea,  we  must  pass  directly  to  the  account  of  our  knowledge 
of  bacteria  of  the  nose  and  throat.  The  presence  of  fungi,  visible 
as  they  are  to  the  naked  eye  when  grown  to  large  masses,  was 
naturally  the  first  to  be  noted. 

Mycoses  Pharyngis. — In  1873  B.  FraenkeP  drew  attention  to  the 
occurrence  in  the  tonsil  and  pharynx  of  what  we  know  as  mycosis 
pharyngis.  In  1882  E.  FraenkeP  and  many  others  since  then  have 
elaborated  the  subject.  Heryng,^  in  1885,  described  the  disease  fully 
from  the  point  of  view  that  the  predominant  organism  produces  the 
masses  of  white  material  seen  protruding  from  the  tonsillar  crypts. 
Seifert,^  in  1893,  in  an  article  on  the  lingual  tonsil  refers  to  the 
literature  of  a  large  number  of  case  reports.  He  also  refers  to  cases 
of  pharyngomycosis  sarcinica,  the  first  one  being  by  Friedreich,^  in 
1864,  and  to  a  much  later  report  by  Fischer,*^  but  this  is  a  condition 
which  has  not  since  then  found  a  place  in  laryngological  literature. 
Chiari^  took  the  correct  view  as  early  as  1887,  claiming  mycosis 
pharyngis  is  not  a  specific  disease  due  primarily  to  bacteria,  but 
to  the  overgrowth  of  the  leptothrix  always  present  in  the  mouth, 
finding  faA'orable  conditions  in  certain  tonsils  for  its  appearance. 
Epstein^  and  Hellat  and  Ucke,^  in  1900,  contributed  papers  to 
the  subject  of  mycosis  pharyngis,  the  former  author  identifying 
the  leptothrix  and  the  latter  writers  speaking  of  a  streptothrix 
as  the  organism  forming  the  Avhite  tufts.  Among  the  peculiar 
medicaments  used  in  the  treatment  was  nicotine  in  the  form 
of  tobacco  smoke.  The  proper  understanding  of  the  anatomical 
features  which  always  accompany  and  often  simulate  tonsillar 
mycosis   dates   back   to  the  article   by   Siebenmann.^'^     In    1895 

1  B.  Fraenkel:  Berliner  klinische  Wochenschrift,  1873,  X,  p.  94. 

2  E.  Fraenkel:  Zeitschrift  f.  klinische  Aledizin,  1882,  IV,  p.  288. 

^  Heryng:  Zeitschrift  f.  khnische  Medizin,  1885,  VII,  Heft  4,  p.  358. 

*  Seifert:  Archiv  fiir  Laryngologie  und  Ilhinologio,  1894,  I,  p.  69. 

^  Friedreich:  Virchow's  Archiv  f.  path.  Anat.,  1864,  XXX,  p.  385. 

®  Fischer:  Deutsches  Archiv  fiir  klinische  IMedizin,  1885,  XXXVI,  p.  344. 

^  Chiari:  Revue  niensuelle  de  laryngologie,  etc..  No.  10,  October,  1887,  VII, 
p.  559. 

^  Epstein:   Priiger  medizinische  Wochenschrift,  No.  22,  1900,  XXV,  p.  253. 

5  Hellat  and  Ucke:  St.  Petersburger  medizinische  Woch.,  No.  44,  1900,  n.  f., 
XVII,  p.  421. 

'•^  Sicbenniann:  Archiv  fiir  Laryngologie  und  Rhinologie,  1895,  II,  p.  365. 


298  BACTERIOLOGY  OF  THE  NOSE  AND   THROAT 

he  showed  that  keratosis  of  the  epithoHum  of  the  tonsillar  crypts 
and  of  the  ducts  of  the  pharyngeal  glands,  causing  the  tufts  of 
white  material  to  appear  as  tufts  of  moulds,  was  practically 
always  present,  and,  as  Fraenkel  had  suggested,  furnished  a,  favor- 
able nidus  for  the  development  of  the  leptothrix  and  other  strepto- 
thrix  forms.  Under  these  names,  as  noted  in  the  bibliography  of 
Siel)enniann,  a  large  number  of  authors  had  written  on  the  subject, 
but  since  then  the  condition  has  been  treated  of  in  laryngological 
literature  as  a  keratosis  of  the  faucial  and  lingual  tonsil  and  of  the 
oropharynx. 

Actinomycosis  of  the  Tonsils. — Another  form  of  fungous  growth  of 
the  tonsil  on  the  other  hand  was  not  ascribed  to  an  organism  at  first 
except  in  a  tentative  way.  Ruge,^  in  189(),  wrote  a  paper  on  actino- 
myces-like  bodies  in  the  crypts  of  the  tonsils.  ]Many  histologists 
had  been  inclined  to  doubt  the  reality  of  these  organisms  existing 
in  the  tonsillar  crypts.  The  general  advance  of  our  knowledge  of 
the  large  number  of  varieties  of  this  organism,^  most  of  them  non- 
pathogenic, rendered  it  probal)le  that  these  clumps  not  uncommonly 
met  with,  in  reality  belong  in  this  class.  The  obser^•ation  of  Wright,^ 
in  1904,  who  demonstrated  sections  of  tonsils  in  which  the  tissue 
was  seen  to  be  invaded  by  the  growth,  furnished  further  evidence 
in  the  matter.  Thevenat*  reported  another  such  case  also  in  1904 
and  referred  to  the  report  of  another  by  Mikulicz.  Wright  also 
refers  to  the  report  of  a  case  by  Lesin,  and  suggests  that  usually 
these  organisms  seen  in  the  tonsillar  crypts  belong  to  non-pathogenic 
varieties.     According  to  a  thesis  of  Lyons  by  Laurent  Clare,  in 

1904,  he  could  find  the  record  of  seven  cases.  Li  1905  Gappisch,^ 
owing  to  tinctorial  reaction  was  inclined  to  believe  that  the 
bodies  described  by  Huge  do  not  belong  to  the  actinomyces  group. 
^Nliodowski*^  also  took  this  view  of  it.  The  matter  seems  largelv  a 
question  of  bacteriological  classification  and  nomenclature  and  the 
difficulty  in  settling  the  uncertainty  is  due  to  the  impossibility  of 
getting  cultures.  Goris^  under  the  title  of  pharyngeal  actinomycosis 
has  reported  a  case  of  which  the  origin  of  infection  seems  to  have 
been  the  tonsil. 

Bacteriology  of  the  Nose. — ^Returning  to  the  bacteriology  of  the 
nose  we  find  that,  as  in  the  throat,  Fraenkel  announced  the 
presence  of  bacteria  in  the  nose  in  1873.  In  the  same  year 
Hueter^  claimed  that  the  microorganisms  observed  in  nasal  secre- 

1  Ruge:  Zeitschrift  fiir  klinischo  Alodizin,  1896,  XXX,  p.  529. 

*  See  paper  by  Howard:  .Journal  of  Medical  Research,  May,  1903,  IX,  p.  301. 
'  Wright:  American  Journal  of  Medical  Sciences,  July,  1904,  CXXVIII,  p. 

74. 

*  Thevenat:  Lyon  M6dical,  1904,  CII,  p.  11G6. 

*  Gappisch:  Verhandlung  der  deutschen  pathologischen  Gesellschaft,  Jahrg., 

1905,  p.  130. 

^  Miodowski:  Archiv  fiir  Laryngologie  und  Khinologie,  1907,  XIX,  p.  277. 
^  Goris:  Journal  de  chir.  et  annal.  de  la  soc,  beige  de  chir.,  1911,  XI,  p.  20. 

*  Hueter:  AUgenieine  Chirurgie,  1873,  p.  257. 


BACTERIOLOGY  OF  THE  NOSE  299 

tions  were  the  cause  of  coryza.  It  was  not,  however,  until  after 
1880  that  the  Hterature  of  the  subject  became  abundant.  Herzog^ 
reported  their  presence  in  the  normal  nose.  B.  Fraenkel,  in 
1886,-  demonstrated  pathogenic  cocci  in  the  nasopharynx.  In 
1889  Von  Besser'^  and  Wright^  were  able  to  demonstrate  their 
presence  likewise  in  the  nasal  chambers  of  healthy  people.^ 

Wurtz  and  Lermoyez'^  published  observations  in  1893  which 
tended  to  iuAalidate  these  conclusions.  They  asserted  not  only 
that  bacteria  in  the  healthy  nose  are  extremely  rare  or  absent,  but 
that  the  nasal  mucus  has  bactericidal  properties.  In  this  contention 
they  were  supported  by  the  work  of  Thomson  and  Hewlett,^  who 
claimed  that  practically  no  bacteria  are  present  in  the  normal 
nose  posterior  to  the  vestibule.  This  was  claimed  to  be  incorrect 
by  Park  and  Wright.  They  repeated  the  former  work  of  Wright 
and  that  of  Thomson  and  Hewlett,  and  showed  that  with  proper 
technique  positive  results  could  nearly  always  be  obtained  from 
culture  plants  made  from  the  intranasal  mucous  surfaces.  They 
asserted  that  the  drip  of  sterile  secretions  from  the  Bowman's 
serous  glands  tends  to  wash  away  such  bacteria  as  are  deposited 
from  the  air  current  and  renders  the  surface  less  rich  in  bacterial 
flora  than  those  regions  which,  like  the  vestibule,  not  only  receive 
the  first  impact  of  bacteria-laden  air  but  are  not  irrigated  from 
above.  They  also  failed  to  find  that  the  nasal  mucus  has  any 
bactericidal  effect.  \'ansant*  and  Viollet^  about  the  same  time 
made  similar  observations.  Hasslauer^'^  collected  a  bibliography 
of  the  subject  in  1906  which  was  exhaustive.  From  the  collation 
of  more  than  200  reports,  more  than  30  of  which  deal  with  the 
bacteria  of  the  normal  nose,  it  appeared  that  in  the  normal  nose, 
not  only  man}'  air  forms  were  found,  but  frequently  pathogenic 
organisms,  such  as  those  of  diphtheria  and  tuberculosis,  the  pneu- 
mococcus  and  pyogenic  cocci,  the  Friedlaender  bacillus,  the  meningo- 
coccus intracellularis  and  the  bacteria  coli.     The  recent  work  of 

1  Herzog:  Wiener  medizinische  Presse,  No.  29,  seq.,  1881,  XXII,  p.  911. 

2  B.  Fraenkel:  Berliner  klinische  Wocheiischrift,  No.  17,  1886,  XXIII,  p.  265. 
^  Von  Besser:  Beitriige  zur  pathologisclien  Anatomie,  1889,  VI,  p.  333. 

*  Wright:  New  York  Medical  Journal,  July  27,  1889,  L,  p.  92. 

5  For  an  account  of  the  discussion  as  to  the  presence  of  microorganisms  in 
the  healthy  nose  see  the  paper  on  Nasal  Bacteria  in  Health,  by  Dr.  W.  H.  Park 
and  Dr.  Jonathan  Wright,  N.  Y.  Medical  Journal,  February  5,  1898,  LXVII, 
p.  178;  Journal  of  Laryngology,  March,  1898,  XIII,  p.  124;  Annales  des  mala- 
dies de  I'oreille,  February,  1898,  XXIV,  Pt.  I,  p.  113. 

^  Wui'tz  and  Lermoyez:  Annales  des  maladies  de  I'oreille,  August,  1893, 
XIX,  p.  961. 

'  Thomson  and  Hewlett:  Medico-Chirurgical  Transactions,  1895,  LXXVIII, 
p.  239. 

^Vansant:  Journal  American  Medical  Association,  February  27,  1897, 
XXVIII,  p.  395. 

^  Viollet:  Comptcs  rendus  de  la  societ6  de  biologic,  December  27,  1899,  LI, 
p.  996. 

"  Hasslauer:  Centralblatt  f.  Bacteriologie  und  Rhinologie,  1  abt.,  Referate, 
1906,  XXXVII,  Nos.  1-3,  p.  1. 


300  ATROPHIC  RHINITIS 

Logan  Tiinu'r'  has  confirmed  this  earlier  work,  thougli  the  work 
of  Cobl)-'  and  Xagle  throws  some  doubt  upon  the  technique.  In 
makiniii;  phmts  from  the  nasal  chambers  tlie  avoidance  of  con- 
tamination in  passing  the  vestibule  was  appreciated  as  a  requisite 
by  Thomson  and  Hewlett.  Park  and  A\'right  believed  they  had 
successfully  met  this  criticism  Avith  which  the  work  of  Cobb  is 
concerned.  Walter,^  in  1910,  made  a  study  of  the  bacterial  flora 
of  the  nasal  mucosa  in  cases  of  rhinitis,  finding  dij)htheroid  baciUi 
and  the  micrococcus  catarrhalis.  He  often  met  with  Friedlaender's 
pneumobacillus  in  chronic  nasal  aft'ections.  Pyogenic  cocci  were 
also  found.  Within  the  last  few  years  it  has  been  shown  by  Flexner* 
and  his  assistants  and  by  Levaditi^  that  not  only  is  the  meningo- 
coccus intracellularis  often  the  inhabitant  of  the  normal  nasal 
cavities,  but  that  both  it  and  the  filtrate  virus  of  poliomyelitis 
infect  the  cerebral  membranes  and  the  brain  and  spinal  cord  from 
the  nose  as  a  focus. 

It  will  be  more  convenient  to  speak  of  the  bacteriology  of  the 
other  aft'ections  of  the  nose  and  throat  in  connection  with  other 
subjects. 

ATROPHIC  RHINITIS. 

The  diseases  with  wliich  the  history  of  our  subject  is  concerned, 
which  have  been  profoundly  affected  in  their  nosology  by  bacterio- 
logical ideas,  are  especially  diphtheria  and  tuberculosis;  but  other 
aft'ections  have  also  been  persistently  ascribed  to  their  influence. 
Atrophic  rhinitis,  accompanied,  as  it  usually  is,  by  the  foul-smelling 
secretions,  very  naturally  fell  under  suspicion.  Loewenberg  de- 
scribed,^ in  1885,  a  bacterium  constantly  found  in  the  secretions  of 
ozsena,  and  this  has  been  many  times  confirmed  by  other  observers 
since  then.  Klamman,^  Thost,^  Seifert,^  Strauch,^**  Valentin," 
Hajek,'-  Reimann,''^  Abel,^^  and  others  contributed  to  the  bacteriology 
of  ozsena  within  a  few  years  after  Loewenberg's  paper,  but  the 

'  Turner:  Archiv  f.  Laryngologie,  1911,  XXV,  p.  265. 
^  Cobb:  Transactions  American  Laryngological  Association,  1909,  p.  73. 
*  Walter:  Journal  American  Medical  Association,  September  24,  1910,  LV, 
p. 1091. 

••  Flexner:  See  a  summary  of  the  subject  in  Science,  November  22,  1912,  n.  s., 
XXXVI,  p.  685. 

^Levaditi:  Comptes  rendus  de  la'soc.  de  biologic,  April  27,  1912,  LXXII, 
p.  651. 
8  Loewenberg:  Deutsch.  med.  Woch.,  Nos.  1,  2,  1885,  XI,  pp.  5,  22. 
'  Klamman:  Allg.  med.  central  Ztg.,  67,  1885,  LIV,  1069. 
8  Thost:  Deutsche  med.  Woch.,  No.  10,  1886,  XII,  p.  161. 
sSeifert:    Volkmann's   Samml.  klin.  Vortriige,    1884,  No.  240  (Inn.    Med., 
No.  84),  p.  2201. 
»"  Strauch:  Monatssch  f.  Ohrenhcilk,  6  and  7,  1887,  XXI,  pp.  149,  181. 
"  Valentin:  Correspondenzblatt  f.  Schweizer  Aerzte,  1887,  XVII,  p.  141. 
12  Hajek:  Berl.  khn.  Woch.,  No.  33,  1888,  XXV,  p.  659. 
1^  Keimann:  Inaug.  Dissert.  Wiirzb,  1888. 
'^  Abel:  Centralblat  fiir  Bakt.,  1893,  XIII,  p.  161. 


ETIOLOGY  AND  HISTOLOGY  301 

etiological  importance  of  a  bacterium,  in  spite  of  much  recent 
literature  as  to  other  germs,  has  not  been  acceptefl  as  preponderat- 
ing in  the  causation  of  atrophic  rhinitis,  and  it  cannot  be  said  that 
bacteriology  so  far  has  materially  elucidated  the  mystery  of  the 
etiology  and  pathology  of  this  disease.  This  is  in  striking  contrast 
with  the  history  of  the  diphtheria  germ,  the  study  of  which  has 
led  to  such  astonishing  results  in  pathology,  diagnosis,  and  therapy, 
and  in  fact  in  biology  in  general. 

Etiology  and  Histology. — V^e  have  noted  the  tendency  to  regard 
the  presence  of  some  one  or  more  of  the  microorganisms  often 
associated  with  it  as  sufficient  to  explain  the  phenomena  of  atrophic 
rhinitis.  With  the  advent  of  a  more  critical  attitude  toward 
bacterial  theories  of  the  etiology  of  disease,  this  tendency  disap- 
peared from  the  discussions  of  the  etiology  of  ozjena  and  atrophic 
rhinitis.  We  have  also  noted  the  tendency  to  ascribe  its  primary 
factor  to  accessory  sinus  suppuration.  This  has  attracted  the 
attention  from  time  to  time  chiefly  of  clinicians,  but  has  failed 
to  satisfy  the  demands  for  an  explanation  of  the  pathological 
histology  of  atrophic  rhinitis. 

It  is  within  a  comparatively  recent  period,  at  a  date  long  sub- 
sequent to  the  in\'ention  of  the  laryngoscope  and  the  application 
of  posterior  rhinoscopy  to  the  study  of  nasal  disease,  that  the 
various  forms  of  chronic  nasal  inflammation  were  differentiated. 
In  1866  Weber,^  who  had  de\'oted  himself  largely  to  the  study  of 
the  ear,  contributed  an  article  to  one  of  the  reference  hand-books 
of  surgery  on  nasal  disease  from  which  it  is  quite  apparent  that 
atrophic  rhinitis  as  we  know  it — non-syphilitic — without  the  presence 
of  a  foreign  body,  was  undifferentiated  at  this  time. 

Zaufal,-  in  1S74,  claimed  that  the  ozai-na  present  in  some  cases 
of  catarrh  is  associated  with  a  congenital  deficiency  in  the  develop- 
ment of  the  inferior  turbinated  bone.  This  idea  that  it  is  connected 
with  a  congenital  bone  defect  was  many  years  subsequently  (1896) 
expanded  in  the  work  of  ]Meisser  to  the  conception  that  it  is  due 
to  an  abnormal  wideness  of  the  nasal  fossae,  which  is  congenital. 
Alexander  quotes  Sauvages^  as  having  claimed  in  17()3  that  it  is  due 
to  the  nose  being  too  narrow.  Ilopmaini,^  again  in  1893,  had  claimed 
the  nasal  fossae  are  congenitally  too  short.  As  recently  as  1908  he 
has  reiterated^  his  belief  in  the  shortening  of  the  septum  as  an  indica- 
tion that  a  congenital  conformation  of  the  nasal  fossie  is  the  cause  of 
ozsena.     Michel"  as  early  as  1876  declared  that  atrophic  rhinitis  is 

^  Weber:  v.  Pitha  and  Billroth,  Handbucli  d.  allu;.  und  spec.  Chirurgic,  Band 
III,  1  abth.,  2  Heft,  p.  177,  ISlHi. 

'  Zaufal:  Aerztl.  Corro.si)ondenzblatt  f.  Bohmcn,  Xos.  23-24,  1874. 

'  Sauvages:  de  la  Croix  Nosologia  Alethodica,  Tome  III,  Amst.,  1763. 

*  Hopmann:  Archiv  f.  Lar3^ngologie  und  Rhinologie,  1893,  I,  Heft  1,  p.  35 

^Hopmann:  Zeilschrifl  f.  Larvngologie,  Khinologie  und  ihre  Grenzgebicte, 
190S,  I,  p.  305. 

^  Michel:  Krankheiten  der  Nasenhohle  und  des  Nasenrachenraums,  Berlin, 
1876. 


302  ATROPHIC  RHINITIS 

essentially  a  disease  of  the  accessory  sinuses.  This  is  still  a  promi- 
nent feature  of  discussions  on  the  etiolojiy  of  accessory  sinus  disease. 
It  rested,  especially  at  that  time,  upon  insufficient  differentiation. 
As  in  almost  every  domain  of  medicine,  history  here  takes  account 
of  the  differentiation  of  phenomena  in  the  course  of  the  discussion 
of  theory  and  the  acquisition  of  our  knowledge  of  facts.  Ilartmann,' 
in  1878,  as  a  result  of  postmortem  examinations,  had  already  refuted 
^Michel's  idea  as  to  the  genesis  of  oziena  in  the  accessory  sinuses. 
He  was  inclined  to  accept  Zaufal's  theory.  Tissier,'-  in  1894,  claimed 
it  to  be  a  bone  disease  of  the  ethmoid  labyrinth  in  the  embryo  and 
the  infant.  The  accessory  sinuses  are  thus  affected  in  his  view 
as  a  continuation  of  a  congenital  condition,  the  secretions  forming 
a  favorable  medium  for  the  growth  of  bacteria,  (ierber,^  in  1900, 
examined  the  question  of  nasal  anomalies  in  their  relation  to  the 
etiology  of  ozsena,  and  came  to  the  conclusion  that  roominess  of 
the  fossw  and  a  depressed  nasal  arch  (chamseprosopia  and  platyr- 
rhinia)  often  combined  with  syphilis  are  predisposing  factors. 
In  later  years  there  has  been  a  recrudescence  of  the  belief  that 
oza^na  is  due  to  a  necrosing  ethmoiditis,'*  and  again  the  ethmoid 
and  sphenoid  cavities  have  been  vigoroush'  attacked. 

Histology. — In  the  early  work  of  B.  FraenkeP  may  be  noted  the 
first  attempt  to  separate  cases  of  true  ozaena  from  those  of  syphilitic 
ozffina.  While  he  thus  erected  the  typical  atrophic  rhinitis  with 
ozaena  into  a  separate  entity,  he  failed  to  indicate  that  it  is  depen- 
dent also  upon  a  bone  change,  as  is  the  ozsena  of  a  syphilitic  nose. 
His  idea  that  it  is  a  specific  change  in  the  secretions  was  a  natural 
prelude  to  the  belief  which  soon  arose  that  this  depends  upon  some 
specific  form  of  bacterial  life.  Naturally  this  left  the  atrophic  bone 
change  even  more  completely  unp^o^•ided  for  than  did  the  sub- 
sequent sinus  theory  of  Griinwald  and  his  followers,  to  which  I 
have  referred  as  starting  with  jNIichel.  Fraenkel  divided  nasal 
catarrhs  into  hyperplastic  and  atrophic,  regarding  the  latter  as  a 
sequel  of  the  former.  Pie  also  admitted  the  infiuence  of  various 
dyscrasi;e  as  etiological  factors.  INfore  than  thirty  years  later  he 
had  the  satisfaction  of  reminding''  his  colleagues  that  this  early 
classification  is  todav  fundamentallv  the  basis  of  dift'erentiation 
of  intranasal  inflammations.     In   1879  Eugen  FraenkeF  studied 

'  Hartmann:  Deutsche  mcdizinische  Wochenschrift,  March  30,  1878,  IV, 
p.  145. 

2  Tissier:  Annales  de  medecine,  January,  March,  1893;  Il)i(l.,  November, 
1893;  Annales  des  maladies  de  I'oreille,  etc.,  No.  10,  October,  1894,  XX,  p.  995; 
L'ozene,  son  unite,  scs  lesions  generatrices,  sa  traitcment,  1894. 

^  Gerber:  Archiv  f.  Laryngologie,  1900,  X,  p.  119. 

■•  Lavrand:  Archives  Internationales  de  larvngologic,  1910,  XXX,  No.  2, 
p.  400. 

'  Fraenkel:  Ziemssen's  Handbuch  der  spez.  Pathol,  uud  Tlicra]).,  1  Aufl., 
1876,  IV,  1  hiilfte,  p.  125. 

*  Fraenkel:  Berliner  lar3'ngolische  Gesellschaft,  ref.  Scmon's  Internat. 
Centralblatt  f.  Laryiigologie,  1907,  XXIII,  p.  115. 

'  Eugen  Fraenkel:  \'ircho\v's  Archiv,  1879,  LXXV,  p.  45. 


HISTOLOGY  303 

sections  of  the  atrophic  nasal  mucosa  under  the  microscope  and 
noted  changes  in  the  epithehum,  though  he  asserted  that  it  is 
destroyed  and  replaced  by  other  cells.  He  remarked  on  the  few 
acinous  glands  to  be  observed.  He  believed  there  is  always  an 
underlying  dyscrasia  of  tuberculosis  or  of  syphilis.  He  believed 
there  are  always  deep  lesions  of  the  mucosa  and  of  the  bone.  In 
the  same  year  Gottstein/  though  believing  in  its  systemic  nature, 
recognized  ozfena  as  a  constant  symptom  of  that  stage  of  a  chronic 
rhinitis  in  which  it  has  come  to  an  atrophy  of  the  mucosa  and  of  the 
glands  in  it.  The  vitiation  of  the  secretions  from  this  cause  he 
proposed  to  treat  by  the  use  of  intranasal  tampons  of  cotton  left 
in  the  nose  for  twenty-four  hours  or  more.     Hermann  Krause,^  in 

1881,  described  microscopic  appearances  in  two  cases  of  ozsena  and 
noted  the  presence  of  evidences  of  fat  and  fatty  acids  in  the  secre- 
tions and  in  the  mucosa,  fibrosis  of  the  stroma  and  bloodvessels, 
and  the  relative  increase  of  lymphoid  cells.  The  destruction  of 
glands  he  believed  to  be  due  to  limitation  of  the  blood  supply  and 
the  fibrosis  of  the  bloodvessels.  These  ideas  were  many  of  them 
introduced  in  America  by  Bosworth  in  several  excellent  papers^  in 
1882  and  in  his  "Treatise  of  the  Diseases  of  the  Xose  and  Throat." 
He  believed  atrophic  rhinitis  with  ozsena  was  usually  the  sequence 
of  a  purulent  rhinitis  in  childhood.  Briigelmann,^  in  1884,  looked 
upon  the  nature  of  ozt^na  as  a  suppuration  of  the  nasal  turbinated 
bones.  He  thought  the  increased  dimensions  of  the  nasal  chambers 
an  anomaly  of  development  and  he  believed  that  this  and  a  scrofu- 
lous diathesis  are  predisposing  factors  in  the  etiology. 

Zuckerkandl  brought  the  discussion  to  its  more  useful  channels 
in  refuting  the  fallacies  of  the  theories  dependent  on  a  congenital 
bone  defect  or  abnormality  and  in  suggesting  that  the  changes  in 
the  bone  are  apparently  the  result  of  an  intra  vitam  inflammatory 
process,  but  it  was  a  number  of  years  before  this  view  became  the 
prevailing  one.  Many  papers  were  written  in  support  of  the  view 
that  it  is  due  to  a  congenital  conformation  of  the  nasal  fossse. 
These  are  reviewed  in  the  paper  of  ]\Ieisser  (1.  c.)  and  the  later 
one  of  Alexander.  The  paper  of  Cholewa  and  Cordes-^  is  to  be 
mentioned  as  claiming  that  the  essential  lesion  is  a  bone  lesion, 
but  a  peculiar  one,  not  of  an  inflammatory  nature.  As  for  the 
changes  observed  in  the  mucous  membrane  itself,  these  have 
been  variously  described  as  primary  and  secondary  to  a  bone  lesion 

1  Gottstein:  Berliner  klinische  Woehenschrift,  No.  37,  September  IG,  1S78, 
XV,  p.  554;  Breslauer  aerztliche  Zoitschrift,  1879,  No.  17.  I,  p.  169. 

2  Krause:  Vii-chow's  Archiv  f.  path.  Anat.,  1881,  LXXXV,  p.  226. 

^  Bosworth:  Transactions  International  Medical  Congress,  1881,  III,  p.  329; 
Medical  Record,  June  10,  1882,  No.  23,  XXI,  p.  617;  Archives  of  Laryngologie, 

1882,  III,  p.  232. 

*  Briigelmann:  Monatsschrift  f.  Ohrcmheilkunde,  1881,  No.  5,  XVII,  p.  91. 
^  Cholewa  and  Cordes:  Archiv  f.  Laryngologie  und   Khinologie,  1898,  \'III, 
p.   18. 


304  ATROPHIC  RHINITIS 

by  numerous  observers,  amont;  whom  we  may  name  ITabermann,' 
in  1S86,  Schoenemann,-in  1902,  Ojjpikofer,''  in  1907,  as  representative 
of  opinions  expressed  at  isolated  times.  The  whole  question  is 
exhaustively  reviewed  by  Alexander.* 

John  N.  Maekenzie,^  in  1884,  expressed  the  belief  that  there  is 
always  a  hypertrophic  stage  to  atrophic  rhinitis.  jNloure'^  declared 
himself  a  sharer  in  the  belief  of  (lottstein  that  the  essential  lesion 
in  atrophic  rhinitis  lies  in  the  glands.  Ilabermann  (1.  c.)  also 
accepted  this  \iew.  The  invohement  of  the  serous  and  mucous 
glands  is  well  established  in  present-day  nasal  histology,  but  it 
has  never  been  generally  accepted  as  a  satisfactory  exposition  of 
the  whole  process  or  of  its  etiology. 

Luc"  and  Bronner,^  in  1887-8,  again  drew  attention  to  the  aj)par- 
ent  association  of  ozjena  and  accessory  sinus  disease.  Griinwald^ 
advocated  this  idea  in  his  book  on  nasal  suppuration  and  that 
other  lesions  also  were  the  cause  of  it,  such  as  adenoid  vegetation, 
etc.  Luc,^"  in  1888,  reported  three  cases  of  tracheal  ozjsna  and  a 
discussion  as  to  priority  in  the  observation  of  the  affection  arose 
with  ]\Iassei.  Zarniko'^  and  others  asserted  that  tracheal  oztena 
may  exist  without  a  nasal  lesion.  Potiquet'-  contributed  a  number 
of  papers  to  the  earlier  discussions  of  atrophic  rhinitis  by  modern 
rhinologists. 

I  have  already  referred  under  the  heading  of  bacteriology  to  the 
literature  of  the  microbian  thec^ries  of  the  etiology  of  oza^na.  The 
similarity  of  the  bacillus  found  by  Loewenberg,  Abel,  and  Paulsen 
in  ozsenatous  cases  with  the  bacillus  of  Frisch  and  of  both  with 
the  bacillus  of  Friedlaender  led  to  much  discussion  as  to  the  con- 
nection of  ozrtMia,  scleroma,  and  pneumonia.^''  While  most  observers 
confirmed  the  early  reports  of  various  bacterial  forms  found  in 
the  secretions  of  ozjena,  no  one  was  able  to  demonstrate  the  pres- 
ence of  any  of  them  in  the  subepithelial  tissue  of  the  mucosa  itself, 
and  some  of  the  reputed  specific  forms  were  found  in  normal  noses 

1  Habermann:  Zcitschrift  f.  Heilkunde,  1SS6,  VII,  p.  361. 
^  Schoenoinann:  Virohow's  Arohiv,  1902,  Band  IGS,  p.  22. 
'  Oppikofcr:  Arrhiv  f.  Laryngologie  vmd  Rhinologie,  1906,  XIX,  p.  28. 

*  Alexandor:  Ibid.,  1909,  XXII,  p.  260. 

'  Mackenzie:  Medical  News,  October  4,  1884,  No.  14,  XLV,  p.  370,  and 
April  4,  1885.  XLVI,  p.  372. 

*  Moure:  Compte  rendu  de  la  societe  fran^aise  d'otologie  et  de  larvngologie, 
1885. 

^  Luc:  Societe  de  medecino  pratique,  February,  1887. 

*  Brenner:  British  Medical  Journal,  March  3,  1888,  I,  p.  471. 

8  Griinwald:  Miinchener  medizinische  Wochenschrift,  1893,  No.  43,  XL, 
p.  809. 

'"  Luc:  Archives  de  larynologie,  etc.,  February  15,  1888,  I,  p.  101;  April  15 
1888,  I,  p.  177. 

'1  Zarniko:  Miinchener  medizinische  Wochenschrift,  1897,  No.  30,  XLIV, 
p.  846. 

'^  Potiquet:  Revue  h6bdomadaire  de  laryngologie,  otologic,  rhinologie,  Janu- 
ary 1,  1890,  X,  p.  8. 

1'  In  addition  to  the  publications  already  referred  to  of  these  authors  sec  those 
of  Striibing:  Miinchener  nicdizinisclie  Wochenschrift,  1895,  No.  39-40,  XLII, 
pp.  900,  933.    Abel:  Zcitschrift  f.  Hygiene,  1896,  XXI,  p.  89. 


HISTOLOGY  305 

or  in  noses  not  the  site  of  atrophic  rhinitis.  Perez^  not  only  dis- 
covered a  cocco-bacillus  as  the  cause  of  ozaena  but  found  it  also 
in  a  dog,  and  injected  into  rabbits  it  caused  gradual  atrophy  of 
the  turbinated  bones.  He  suggests  that  it  is  acquired  by  man 
from  the  dog,  Hajek,-  who  made  investigations  on  the  bacterial 
contents  of  the  nose,  expressed  his  belief  that  the  organisms  found 
in  ozaenatous  cases  had  little  or  nothing  to  do  with  the  etiology 
of  the  disease.  He  believed  that  atrophic  rhinitis  has  always  a 
preliminary  stage  of  hypertrophy.  In  the  discussion  on  his  paper 
in  1S87,  in  which  he  asserted  this  and  that  the  Friedlaender  bacillus 
often  found  in  the  nose  plays  a  secondary  part  even  in  pneumonia, 
he  was  opposed  b}^  Weichselbaum,  Paltauf,  and  Roth. 

Siebenmann,^  who  was  a  collaborator  with  Meisser  in  the  exami- 
nation of  cranial  form  as  a  factor  in  the  etiology  of  ozsena,  made 
a  careful  study  of  the  histology  of  atrophic  rhinitis,  but  he,  as  many 
other  writers,  laid  a  stress  upon  the  specificity  of  the  metaplasia  of 
the  epithelium  of  the  surface  which  would  not  have  been  the  case 
if  such  work  had  been  controlled  sufficiently  by  the  examination 
of  this  element  in  normal  noses  and  in  other  pathological  conditions, 
since  in  adult  life  there  is  always  much  of  it  to  be  noted.  Cozzolino* 
believed  the  lesion  first  begins  as  a  keratosis  of  the  surface  epithe- 
lium and  becomes  secondarily  a  bone  disease.  There  was  a  tendency 
with  many  authors,  as  with  Rethi,^  for  example,  to  consider  the 
ozsena  as  something  specific  and  aside  from  the  anatomical  lesions 
of  atrophic  rhinitis. 

I  have  noted  that  from  time  to  time  authors  had  incidentally 
remarked  on  the  connection  of  tuberculosis  and  ozsena,  owing  to 
their  having  a  common  basis  in  malnutrition.  Theisen,^  in  1904, 
made  it  the  subject  of  a  paper.  Broeckaert^  contributed  to  the 
study  of  its  histology  the  expression  of  his  opinion  that  the  disease 
was  due  to  a  toxin  produced  by  a  parasyphilitic  or  a  paratuberculous 
systemic  infection.  These  terms  came  into  use  about  this  time 
and  their  exact  pathological  significance  is  still  enshrouded  in 
mystery.  Frese^  was  of  the  opinion  that  most  of  the  cases  are  of 
syphilitic  origin.  Sobernheim,'^  in  1909,  reported  that  seventeen 
cases  of  typical  ozsena  gave  a  negative  Wassermann  reaction, 
adding  another  proof  to  the  view  that  the  nasal  aftection  may  exist 
without  any  syphilitic  antecedent.     A  number  of  others  testified 

1  Perez:  Internat.  Centralblatt  f.  Laryngologie,  1909,  XXV,  p.  98. 

-  Hajek:  Berliner  klin.  Wochenschrift,  1S8S,  XXV,  p.  659. 

^  Siebenmann:  Correspondenzblatt  f.  Schweizer  Aerzte,  Heft  5,  1900,  XXX, 
p.  129. 

■*  Cozzolino:  Annales  des  maladies  de  I'oreille,  etc.,  April,  1894,  XX,  p.  492. 

^  Rethi:  Archiv  f.  Laryngologie  und  Rhinologic,  1894,  II,  p.  194. 

^  Thei.sen:  Transactions  American  Laryngological  Association,  1904,  p.  130. 

'  Broeckaert:  La  Presse  d'oto-Iaryngologique  beige,  1905,  No.  7,  IV,  p.  317. 
Ref.,  Internat.  Centralblatt  f.  Laryngologie,  1901),  XXII,  p.  404. 

*  Frese:  Archiv  f.  Laryngologie  und  Rhinologic,  1908,  XX,  p.  459. 

sSobernhoim:  Internat.  Centralblatt  f.  Laryngologie,  1909,  XXV  p.  318. 
Archiv  f.  Laryngologie  und  Rhinologie,  1909,  XXII,  p.  1. 

20 


306  ATROPHIC  RHINITIS 

to  the  same  effect.  It  was  spoken  of  as  a  larval  tuherciilosis.^ 
Schoencmanii,-  in  1909,  traced  a  connection  between  the  occurrence 
of  eczema  and  that  of  oztena.  From  time  to  time  various  authors 
have  suggested  that  ozfena  is  a  trophoneurosis.^ 

Treitel^  made  an  attempt  to  determine  the  age  at  which  oztiena 
first  shows  itself  and  concluded  that  in  the  great  majority  of  cases 
it  was  in  the  scliool  age  of  children  that  it  de\eloped — f(uir  to 
fourteen  years.  In  all  treatises  on  the  subject  since  the  affection 
was  first  differentiated  by  B.  Fraenkel,  the  preponderance  of  the 
female  sex  in  the  cases  affected  by  it  was  noted. 

Treatment. — The  treatment  of  atrophic  rhinitis,  especially  of 
its  chief  symptom,  oz;ena,  has  been  varied.  Going  back  to  the 
time  of  its  differentiation,  we  \m\e  already  noted  that  tampons 
were  recommended  by  Gottstein  and  in  the  earlier  history  of 
rhinology  we  have  seen  that  this  was  a  common  form  of  treatment 
for  all  nasal  affections,  the  linen  or  other  absorbent  tampon  being 
saturated  with  various  medicaments.  Cauterization  was  also 
recommended  by  the  ancients  for  what  they  called  ozjena,  and  in 
1884-5  it  was  recommended^  again  as  a  therapeutic  agent  in  its 
modern  differentiation.  In  most  of  the  writers  on  the  subject 
recommendation  for  treatment  included  thorough  cleansing  and 
the  application  subsequently  of  some  stimulating  medicament, 
like  thymol,  aristol,  turpentine,  ichthyol,  etc.  Braun,  Laker,  and 
Demme''  recommended  (1891)  vibratory  massage.  This  was 
employed  by  others,  either  by  hand  or  by  electricly  driven  machin- 
ery. Faradism  was  also  used,^  also  the  electrolytic  application 
of   chloride  of   copper,^   and   submucous   electrolysis.^     I)ionisio^° 

1  Caboche:  Annales  des  maladies  de  I'oreille,  etc.,  September,  1907,  XXXIII, 
p.  260. 

2  Schoenemann:  Verhandlungen  des  Vereins  deutschei'  Larvngologen,  1909, 
p.  168. 

^  Jouty:  Archives  internationales  de  laryngologic,  1909,  XXIX,  No.  .3,  p. 
787.  Baumgartcn:  iVi'chiv  f.  Laryngologic  imd  Khinologie,  1909,  No.  22,  p. 
492.    Lavrand:  Archives  internat.  de  laryngologic,  etc.,  1910,  XXX,  p.  400. 

*  Treitel:  Archiv  f.  Laryngologic  und  Rhinologie,  1904,  XVI,  p.  336. 

'  Garrigou-Dcsarenes,  Du  catarrhe  chronique  .  .  .  des  fosses  nasales  et 
de  I'ozenc;  traitoment  par  la  galvano  caustique  chimique,  Paris,  1888.  Abeille: 
Courrior  mcdicalt!,  188.5,  XXXV,  p.  448.  Ref.,  Internat.  Centralblutt  f.  Laiyn- 
gologie  und  Khinologie,  1886,  III,  p.  6. 

8  Braun:  Wiener  medizinische  Blatter,  1890,  XIII,  p.  547;  Verh.  d.  X  Int. 
Med.  Cong.,  1890,  IV,  abt.  12,  p.  112.  Laker:  Die  Heilorfolgc  der  inneren 
Schleiinhautniassage  .  .  .  Graz,  1892.  Denime:  Deutsche  medizinische 
Wochenschrift,  1891,  No.  46,  XVII,  p.  1262.  For  mechanical  devices  for  vibra- 
tory massage  of  the  mucosa  for  this  and  other  affections  see  Daae:  Archiv  f. 
Laryngologic  und  Rhinologie,  1895,  II,  p.  265.  Jankau:  Monatsschrift  f. 
Ohrenheilkunde,  1897,  No.  5,  XXXI,  p.  207. 

'  Garrison:  Journal  of  Ophthalmology,  Otology  and  Laryngology,  October, 
1893,  V,  1).  343. 

**  Jouslain:  Revue  internationale  d'electrotherapie,  21,  April,  1892,  II,  p.  258. 

^  Cheval:  Revue  de  laryngologic,   August    1,    1895,   XV,   p.   695.      Bayer: 

-Miinchener  medizini.sche  Wochenschrift,   Nos.   32-33,  1896,  XLIII,  pp.  744, 

774.     Revue  h^bdomadaire  de  laryngologic,  1896,  No.  22,  XVI,  p.  641. 

.  1"  Dionisio:  Giornale  del  R.  Accadcmia  di  Mcdicina  di  Torino,  Januarj',  1902, 

Anno  65,  Ser.  4,  VIII,  p.  44;  July-August,  1903,  Anno  66,  iSer.  4,  IX," p.  .506. 


TREATMENT  307 

employed  various  forms  of  phototherapy  in  ozjena,  and  in  the  same 
year  (1903)  Casassa^  reported  on  the  therapeutic  use  of  radium. 

Brindel,^  in  1902,  inaugurated  the  treatment  of  oz.iena  by  the 
injection  of  paraffin  under  the  atrophied  mucosa  and  this  method 
of  treatment  has  persisted  to  the  present  time,  it  being  strongly 
recommended  by  Hutter^  ten  years  later.  Broeckaert,^  who  adopted 
the  idea  promptly,  subsequently  supplemented  it  by  more  vigorous 
measures.  It  was  practised  l)y  Fliess^  and  by  many  other  rhinol- 
ogists  for  a  time  after  this  until  the  report  of  an  embolus  of  the 
retinal  artery  in  two  or  three  cases  of  the  injection  of  paraffin  in 
the  skin  of  the  nose  discouraged  for  a  while  frequent  resort  to  it. 
On  the  strength  of  his  belief  that  atrophic  rhinitis  with  ozaena 
was  the  result  of  a  disease  of  those  cavities,  Broeckaert,''  in  1905, 
in  addition  to  the  use  of  paraffin  proposed  to  operate  radically 
on  the  ethmoidal  sinuses  and  to  curette  the  sphenoid.  He  remo\ed 
the  middle  turbinate,  allowing  the  inferior  to  remain,  reinforcing 
it  with  paraffin  injections  and  injections  of  it  also  into  the  septal 
walls  and  floor  of  the  nose.  He  proposed  also  to  destroy  the  naso- 
sinusal  wall  of  the  antrum,  but  not  to  curette  the  latter  unless  it 
was  diseased.  He  claimed  the  injection  of  paraffin  was  efficient 
not  only  as  a  prothesis  filling  out  the  large  spaces,  but  as  a  stimulant 
modifying  the  nutrition  of  the  mucosa.  Guyot"  employed  suction 
of  the  nasal  chambers  by  mechanical  methods  in  the  treatment 
of  oztena.  A  numlier  of  cases  were  treated  with  injection  of  anti- 
diphtheritic  serum  because  diphtheroid  bacilli  were  found  in  the 
crusts,  chiefly  by  Italians.*^  Skillern  and  Holmes^  used  vaccines 
made  from  the  pure  culture  of  the  Abel  bacillus.  Emulsions  of 
the  culture  of  the  lactic  acid  bacillus  have  been  used  by  many  in 
the  treatment  of  ozaena."  Foy,^^  in  1911,  claimed  considerable  benefit 
can  be  attained  by  the  patients  being  taught  to  breathe  persistently 

^  Casassa:  Archivio  Ital.  di  Otologia,  Rhinologia  e  Laryngologia,  August, 
1903,  XIV,  p.  464. 

^  Brindel:  Pressc  medicale,  June  7,  1902,  X,  p.  .540. 

^  Hutter:  Archiv  f.  Laryngologie  und  Rhinologie,  1911,  XXIV,  p.  189. 

^Broeckaert:  La  Belgique  Aledecino,  Nos.  42-43,  1903,  X,  pp.  70.5,  723; 
Annales  des  maladies  de  Toreille,  etc.,  1903,  XXIX,  pt.  2,  p.  59. 

^  Fliess:  Berliner  laryngologische  Gesellschaft,  November  13,  1903;  Ref., 
Internat.  Centralblatt  f.  Larj^ngologie  und  Rhinologie,  1904,  XX,  p.  255. 

^  Broeckaert:  La  Presse  oto-laryngologique  beige,  1905,  No.  7,  IV,  p.  317; 
1906,  No.  5;  Belg.  oto-laryngologische  Gesellschaft,  December  10,  1905;  Ref., 
Internat.  Centralblatt  f.  Laryngologie,  1906,  XXII,  p.  273. 

'  Guyot:  La  Clinique,  (Briixelles)  1906,  No.  24,  XX,  p.  468. 

*  Belianti  and  tlella  Vedova,  Gradenigo,  Arslan  and  Caterina:  .\rchivio 
Italiano  di  Otologia,  Nos.  2-3,  1896,  IV,  pp.  189,  195,  331.  Compaired:  Annales 
des  maladies  de  I'oreille,  etc..  No.  5,  1897,  XXIII,  pt.  1,  p.  464.  IMoiinie: 
Annales  des  maladies  de  I'oreille,  etc.,  No.  4,  1899,  XXV,  pt.  1,  p.  430. 

'  Skillern  and  Holmes:  New  York  Medical  Journal,  August  15,  1908,  Vol. 
88,  p.  307. 

'"  Stcpinski:  Archives  internationales  de  laryngologie,  1910,  XXX,  p.  79. 

"  Foy:  Annales  des  maladies  de  roreill(>;  1911,  No.  12,  XXXVI,  i)t.  2, 
p.  531. 


308  TUBERCULOSIS  OF   THE   UPPER  AIR  PASSAGES 

and  properly  through  the  nose.      Oz.Tna  has  been  treated  with 
hot  air,  dry  or  moist.' 

In  the  January,  1912,  number  of  Senion's  "Centralblatt  fiir  Laryn- 
gologie,"  etc.,  there  is  a  very  valuable  review  of  the  literature  of 
ozsena  during  the  years  1909,  1910,  1911  by  Alexander.  Among 
the  points  to  which  he  gives  prominence  is  the  inequality  in  the 
distril)ution  of  cases  geogra])hi('iilly,  racially  and  socially,  its 
incidence  as  to  sex  and  age.  lie  drew  attention  to  the  fact  that 
while  the  Wassermann  reaction  in  his  own  experience  and  in  that 
of  others  had  gWen  negati\'e  results  in  cases  of  oza>na,  he  had  him- 
self seen  a  typical  case  of  oz^na,  the  ofl'spring  of  a  syphilitic 
father,  the  sister  of  a  congenitally  syphilitic  brother,  and  in  her 
case  the  Wassermann  reaction  was  also  negative.  He  also  drew 
attention  to  the  fact  that  while  ozti^natous  subjects  rarely  contract 
syphilis,  such  cases  have  been  reported  by  Fraenkel  and  Sobernheim 
(1.  c.)  and  others,  and  that  the  question  of  the  relationship  of  true 
ozaena  to  s\philis  is  not  bv  anv  means  settled.  It  mav  be  remarked 
that  the  subject  is  much  embarrassed  by  the  confusion  which  still 
reigns  as  to  the  clinical  differentiation  of  the  cases.  With  syphilitic 
oza?na  on  the  one  hand  and  atrophic  rhinitis  on  the  other,  without 
crusts  or  odor,  it  is  difficult  for  an  author  to  keep  constantly  in 
view  the  typical  cases  of  atrophic  rhinitis  with  oza'ua.  The  con- 
fusion is  increased  by  the  introduction  of  the  consideration  of 
accessorv  sinus  disease  attended  b\'  intranasal  crust  formation. 
In  this  excellent  review  it  can  be  plainly  seen  that  with  the  exception 
of  the  therapy,  which  is  always  new,  optimistic,  and  futile,  there 
has  been  scarcely  a  question  raised  in  the  literature  of  the  subject 
during  the  three-year  period  with  which  it  is  concerned  that  had 
not  been  thoroughly  discussed  in  the  former  three  decades  in 
discussions  of  the  phenomena  presented  by  oztena. 


TUBERCULOSIS  OF  THE  UPPER  AIR  PASSAGES. 

We  must  now  continue  our  study  of  the  history  of  tuberculosis 
in  the  upper  air  passages.  There  can  be  no  doubt  that  the  recog- 
nition of  the  bacillus,  as  the  specific  agent  of  contagion,  had  very 
much  to  do  with  the  stimulation  of  the  hope  of  finding  a  cure  for 
its  manifestations  in  the  upper  air  passages.  Its  recognition  in  the 
early  part  of  this  century,  confused  as  it  was  with  syphilis,  was 
nevertheless  enough  for  the  formation  of  a  hopeless  prognosis.  The 
differential  diagnosis  between  syphilis  and  tuberculosis  of  the 
lar^'nx  was  still  very  incomplete  when  laryngoscopy  came  into 
use.     Notwithstanding  the  false  idea  of  Louis,  which   liheiners' 

'  Thost:  Congres  Iiitcnuitioiuil  ilc  iiuMlccinc,    I'JO'J,  Sec.   15,   Proc.  ver.,  p. 
29.    Moller:  Verhandlungcn  dcs  Vereins  dcutschcr  Laryngologcn,  1910,  p.  318. 


MIXED  INFECTION  309 

contributions'  liad  fostered,  as  to  the  frequent  coincidence  of 
catarrhal  laryngeal  ulcers  with  tubercular  disease  of  the  lungs, 
Tiirck's  Atlas  and  his  graphic  descriptions-  in  ISfifi  did  much  to 
familiarize  observers  with  the  varying  appearances  of  syphilitic  and 
tubercular  laryngitis.  Five  years  before  this  Gerhardt  and  Roth  had 
recorded  their  experiences  in  the  observation  of  cases  they  called 
syphilitic  disease  of  the  larynx,^  but  at  that  early  date  in  laryngo- 
scopy much  confusion  in  the  differential  diagnosis  is  to  be  expected. 

Mixed  Infection. — In  fact,  we  verv  earlv  find  the  observation  of 
what  is  still  supposed  to  be  the  combined  form  of  syphilitic  and 
tubercular  laryngitis.  Schnitzler  wrote  of  it  in  1868,'*  and  sub- 
sequently returned  to  the  subject  with  increased  interest  and 
wider  experience  in  1890.^ 

^'irchow's  remarks  on  tubercle  threw  a  flood  of  light  on  the 
morbid  processes  in  the  lungs,  and  did  more  than  anything  else 
to  dispel  the  confusion  which  reigned  as  to  the  pathogenesis  of 
tubercle  and  its  affinities  to  caseous  degeneration.  It  seems  wonder- 
ful reading  now,  forty  years  after  it  was  written,  that  about  the 
only  gaps  he  left  in  the  correct  description  of  the  pathogenesis 
of  tubercle  were  those  which  later  were  filled  by  the  disco\ery  of 
the  tubercle  bacillus.  He  thus  refers  to  laryngeal  tubercle:  "In 
the  very  frequent  tuberculosis  of  the  larynx,  small,  flat,  clear, 
gray,  or  whitish-gray  swellings  are  found,  which  hardly  project 
beyond  the  surface."*^  He  rejected,  with  Rokitansky,  the  idea  of 
Louis  that  laryngeal  ulcers  in  phthisis  pulmonalis  are  due  to 
mechanical  causes,  and  he  declared  the  larynx  is  one  of  the  best 
places  in  the  body  to  study  tubercle.  In  the  matter  of  laryngeal 
ulceration  he  was  not  supported  by  Rindfleisch,"  who  to  some  extent 
accepted  the  xiew  of  Louis.  Ten  years  later  we  may  note  Bosworth 
maintaining  the  non-tubercular  character  and  the  curability  of 
laryngeal  ulceration  in  phthisis.^  Schech,-^  in  the  following  \ear, 
while  admitting  their  occurrence,  regarded  it  as  very  rarely 
simple  catarrhal,  but  usually  as  tubercular.  Krishaber,  in  1881, 
while  not  reluctant  to  admit  that  laryngitis  arising  in  a  tubercular 
subject  may  become  ulcerative,  without  the  morbid  process  ha\'ing 
pre^•iously  existed  at  that  point,  ne\"crtheless  recognized  the 
tubercular  form  to  be  the  usual  one."^  Perhaps  the  last  important 
recrudescence  of  this  attractive  idea  of  Louis  is  to  be  noted  in  the 

1  Inaugural  Thesis,  Die  Histologie  dcs  Kt^ilkopfs,  lSr)2.     Rheincr:  Virchow's 
Ai'chivf.  path.  Anat.,  ISf^-i,  V,  p.  .534;  Ueber  den  I'lcerationprozess  im  Kehlkopf. 
^  Tiirck:  Khiiik  (l(>r  Krankheiten  des  Kehlkopfs,  ^^'ien,  ISIiG. 
3  Gerhardt  and  Koth:  \irchow's  Archiv  f.  path.  Anat.,  iStil,  XXI,  p.  7. 
^  Schnitzler:  Wiener  nied.  rre.s.se,  IStjS,  No.  14,  seq.,  IX,  321. 
^  Virchow:  International  klin.  Rmidsehau,  1890,  Xo.  34,  seq.,  IV,  j).  1402. 
*  Die  Krankhaften  Geschwiilste,  1864-."),  liand  II,  p.  G42. 
'  Lehrbuch  der  i:)ath.  Gewebelehre,  L(>ii)zig,  18r)7-()9. 

8  Bosworth:  lioston  Med.  and  Surg.  .Journ.,  April  17,  1879,  C,  p.  544. 

9  Schech:  Aerztl.  Inteliigenzblatt,  ISSO,  Xo.  41,  XXVII,  p.  443. 
"  Ivi-ishabcr:  Trans.  Internat.  .Med.  Cong.,  1881,  III,  p.  208. 


310  TUBERCULOSIS  OF  THE   UPPER  AIR  PASSAGES 

monographs  of  Heryng/  in  1884,  -vvlio  insisted  that  lie  had  observed 
ten  cases.  I)oiil)tless  tlie  entertainment  of  this  belief  liad  nuieh 
to  do  witli  the  snbsequent  entiuisiastic  manner  in  which  he  sought 
and  claimed  the  attainment  of  a  cnre  for  tubercular  laryngitis. 

Forms  of  Tuberculosis. — It  early  became  apparent  that  the 
lesions  of  tuberculosis  Avere  multiform.  In  the  early  days  of  our 
knowledge  of  the  tubercle  bacillus,  lupus  of  the  skin  was  supposed 
to  have  nothing  to  do  with  tuberculosis  of  the  skin,  but  the  identi- 
fication of  lupus  of  the  skin  with  tuberculosis  soon  became  formally 
established  and  the  identification  of  certain  forms  of  tuberculosis  in 
the  throat  with  the  lesions  upon  the  skin,  which  are  placed  under  the 
classification  of  lupus,  was  introduced  into  laryngeal  nomenclature 
shortly  before  the  close  of  the  nineteenth  century.  Tuberculoma 
appears  to  have  been  noted  by  Tobold,  ]\landl.  Stork,  Michel, 
Ariza^  at  an  earlier  date,  but  in  1882  John  X.  Mackenzie^ 
specifically  under  that  head  described  a  tumor  of  the  larynx.  j\Iany 
have  been  reported  since  that  date,  most  recently  by  Sanderson.'* 
It  was  a  matter  of  some  clinical  importance  from  a  difi'erential  diag- 
nostic stand-point  that  the  occurrence  of  smooth,  non-ulcerative 
tumors  of  the  upper  air  passages  should  be  recognized  as  occa- 
sionally being  due  to  tuberculosis. 

Primary. — In  ISSl  interest  was  aroused  by  the  discussion  as 
to  the  (|uestion  of  the  occurrence  of  a  primary  tubercular  laryngitis.^ 
Fraenkel  declared  he  had  seen  instances  of  it  in  which  pulmonary 
phthisis  had  later  supervened.  Voltolini  doubted  if  this  were 
actually  the  case.  Krishaber  declared  he  had  never  seen  a  case 
recover,  but  others  w^ere  less  skeptical,  while  Gerhardt  thought 
catarrhal  ulcers  in  pulmonary  phthisis  subsequently  became 
tuliercnlar. 

Infection. — The  health  officer  of  Florence  in  1754  published  an 
edict  to  avoid  the  consequences  of  phthisical  disease  in  which 
every  physician  of  Tuscany  was  charged  to  report  to  the  city 
tribunal  every  case  of  phthisis  in  such  form  that,  in  case  of  death, 
proper  disinfecting  methods  might  be  ad()])ted.  They  were  to 
see  that  excrementitious  matter  was  carefully  remoxcd  and  that 
spitting  cui)s  should  be  employed  which  should  be  frequently 
changed  and  washed.  After  death,  clothes  and  linen  were  to  be 
boiled  twice  in  a  solution  of  lye;  the  furniture  brushed  and  washed 
twice  and  the  wall  white-washed.  r)(K)rs  and  windows  were  to  be 
freely  o])ened,  that  the  air  might  fully  dissipate  the  infection.'"' 

The  contagiousness  of  phthisis  had  been  asserted  from  time  to 
time    in    the    history   of  medicine,   and  Mllemin   had   proved  it 

1  Ilcryiifr:  Contribution  a  ri'tudo  des  6rosions,  dites  catarrhalos. 

^  See:  Ti'avilmann,  Arcliiv  fiir  Larvnfrolof^ie,  1901,  XII,  ]).  27. 

3  Mackenzie:  Archives  of  M«>dicine,  N.  Y.,  October,  1S82,  VIll,  p.  107. 

*Sander.son:  The  British  Medical  Journal,  April  5,  1918,  I,  p.  703. 

*  Vid.:  Trans.  Internal.  Med.  Coiifrress,  ISSl,  III,  p.  213. 

*  Rpvue  Scientifique,  .htne  1,^,  1912,  L,  1  semestre,  p.  754. 


THE  ROUTES  OF  INFECTION  311 

experimentally  in  animals,  but  it  remained  for  Koch,  who  had 
noted  the  spores  of  the  anthrax  bacillus  in  1876,  to  demonstrate 
the  tubercle  bacillus  in  1882.  Immediately  the  diagnostic  \'alue 
of  its  identification  in  ulcers  of  the  larynx  was  appreciated,  though 
perhaps  somewhat  exaggerated,  by  Fraenkel,  in  1883,^  in  establishing 
their  tubercular  character.  Much  stress  was  also  laid  on  this 
diagnostic  value  of  the  bacillus  by  Hunter  ^Mackenzie-  and  Voltolini.'' 
The  latter,  however,  doubted  the  proof  of  its  infectiousness  in  man. 

The  methods  of  general  infection  in  tuberculosis  is  a  matter  of 
considerable  interest  to  the  laryngologist,  but  the  history  is  one 
of  general  medicine,  and  I  can  only  refer  to  it  in  an  incomplete 
manner.  The  numerous  works  of  Koch  and  Fliigge  seemed  to 
demonstrate  the  method  of  infection  of  the  lungs  is  by  direct 
inhalation  of  bacilli  floating  in  the  air  current.  The  work  of  Hilde- 
brandt^  and  of  Wright'^  and  others  seems  to  show  that  a  large  number, 
if  not  all,  of  the  microorganisms  in  the  inspired  air  are  deposited 
on  mucous  surfaces  before  they  reach  the  lungs.  It  was,  early  in 
the  history  of  bacteriology,  rendered  very  probable  that  once 
deposited  on  the  damp  surfaces  of  the  mucosa?  of  the  upper  air 
passages  the}'  are  not  aspirated  by  subsequent  inhalations  into 
the  pulmonary  tract.*^  Straus^  and  Freudenthal,*  in  1895  and  1896, 
reported  finding  tubercle  bacilli  in  apparently  healthy  noses,  where 
they  had  been  deposited  by  the  air  current  upon  the  damp  surfaces. 

The  Routes  of  Infection. — In  1885  Arnold^  had  first  shown  the 
apparent  origin  of  anthracosis  in  the  lungs  to  be  by  way  of  the  air 
current.  Improbable  as  this  seemed  to  be  in  the  face  of  the  con- 
sideration that  the  bacterial  contents  of  the  inspired  air  would  be 
deposited  upon  the  damp  surfaces  and  that  the  residual  air  in  the 
lungs  extends  into  the  bronchi,  the  infection  directly  from  the  air 
current  was  not  at  first  called  into  cjuestion,  but  in  1902  Saenger^" 
denied   this  and,  in  1905,  Yansteenberghe  and  Grysez^^  adduced 

1  Fraenkel:  Berliner  klinische  Wochenschrift,  January  22,  1S83,  XX,  p.  45; 
April  7,  1884,  XXI,  p.  214. 

2  Hunter  Mackenzie :  Edinburgh  Aled.  Journ.,  February,  1884,  XXIX,  p.  681. 

3  Voltolini:  Allg.  Wien.  med.  Ztg.,  13,  14,  1884,  XXIX,  p.  137, 149;  Monatssch. 
f.  Ohrenheilk.,  3  and  4,  1S84,  XVIII,  37,  57. 

^  Hildebrandt:  Ziegler's  Beitriige  zur  pathologischen  Anatomie,  1888,  II,  p. 
411. 

=  Wright:  New  York  Medical  Journal,  July  27,  1889,  L,  p.  92. 

«  Xenninger:  Zeit.schrift  f.  Hygiene,  1901,  XXXVIII,  p.  94.  Paul:  Zeit- 
schrift  f.  Hygiene,  1902,  XL,  p.  468.  Ficker;  Archiy  fiir  Hygiene,  1905,  LIIL 
p.  50;  LIV,  p.  354.  Bartel:  Wien.  klinische  Wochenschrift,  1905,  1905,  1907. 
Beitzke:  Virchow's  Archiy,  1906,  Band  184,  p.  1;  1907,  Band  187,  p.  183;  1907, 
Band  190,  Beiheft,  p.  58;  1908,  Band  194,  Beiheft,  p.  225.  Verhandhuigen  der 
deutschen  pathologischen  Gesellschaft,  1912,  XV,  p.  100. 

'  Straus:  Tuberculose  et  son  bacillc,  Paris,  1895. 

*  Freudenthal:  Archiy  fiir  Laryngologie,  1896,  V,  j).  124. 

'  Arnold:  IJntersuchungen  fiber  Staubinhalation  und  .Staul)inetastase,  1885. 

"  Saenger:  Virchow's  Archiy  f.  path.  Anat.,  1902,  Band  167,  Heft  1,  p.  116. 

11  Vansteenberghe  and  Grysez:  8ur  I'origine  intestinale  de  I'anthracose 
pulmonairc,  Aiuialos  de  I'lnstitut.  Pasteur,  1905,  XIX,  p.  787.  Calmette  and 
Gu^rin:  Annalcs  de  I'lnstitut.  Pasteur,  1906,  XX,  p.  353. 


312  TUBERCULOSIS  OF  THE  UPPER  AIR  PASSAGES 

evidence  that  its  origin  is  intestinal,  carried  down  the  gastro- 
intestinal canal,  absorbed  and  carried  to  the  lungs  in  the  lymph 
current,  though  A'illard  is  said  to  have  asserted  this  as  long  ago  as 
1862  for  anthracosis.  Beitzke/  in  1900,  strongly  combated  this 
assumption  and  by  experimental  e\idence,  which  included  tying 
off  one  bronchus  in  a  narcotized  animal,  showed  that  the  dust  was 
to  be  foimd  after  inhalation  experiment  only  in  the  lung  which 
had  not  been  cut  off'. 

Materially  influencing  all  the  ideas  of  infection  of  tuberculosis 
was  the  assertion  of  v.  Behring,-  who,  in  IIH).'),  expressed  the  belief 
which  has  been  entertained  ever  since  by  increasing  numbers  of 
medical  men  that  the  tubercle  bacillus  enters  the  system  of  all 
human  beings  in  an  early  period  of  life,  in  the  majority  of  cases  in 
infancy  and  adolescence,  and  remains  dormant  there  perhaps  until 
late  adult  life.  His  assertion,  however,  that  the  infection  thus 
contracted  in  childhood  is  of  bovine  origin  has  not  been  sustained, 
though  the  extent  to  which  it  is  due  to  the  bovine  and  the  human 
type  of  bacillus  respectively  had  not  been  settled. 

The  paper  of  Pfliigge,'^  published  in  1904,  attracted  some  attention. 
His  idea  was  that  the  bacillus  is  carried  in  globules  of  sputum 
coughed  out  by  phthisical  patients.  This  led  many  laryngologists 
to  take  precaution  to  avoid  infection  by  interposing  glass  screens 
between  themselves  and  the  patients  they  were  examining.  He 
denied  that  the  tubercle  bacillus  was  ubiquitous  in  spite  of  the 
statistics  of  Naegeli,  who  had  asserted  that  practically  all  of  the 
human  race  shows  evidence  of  previous  tuberculous  infection  at 
postmortem  when  they  are  forty  years  old.  Much  interest  was 
excited  at  one  time  in  the  discussion  as  to  the  question  of  whether 
tubercle  always  develops  at  the  site  of  the  entrance  of  the  bacillus 
into  the  tissues.  Baumgarten^  and  his  school  were  ad\ocates 
of  this  idea,  which  has  not  received  extensive  endorsement,  since 
it  would  negative  the  idea  of  primary  surface  infection  by  way  of 
the  upper  air  passages  in  any  but  a  Aery  small  proportion  of  those 
cases  showing  pulmonary  or  other  tuberculous  lesions.  We  have 
already  spoken  of  the  infection  of  the  tonsils  with  tuberculosis 
and  of  the  literature  which  arose  concerning  latent  tubercle  in 
the  lymphoid  tissue.  Virchow  as  early  as  1868  had  surmised  that 
a  more  careful  examination  would  reveal  this  lesion  in  the  tonsils, 
and  in  almost  his  last  publication,  in  1902,^  he  reiterated  also  a  i)re- 
vious  statement  in  regard  to  the  difference  between  the  anatomical 

^  Beitzke:  1.  c. 

*  V.  Behring:  Deutsche  medizinische  Wochenschrift,  September  24,  1903, 
XXIX,  p.  GS'J. 

^  Pfliigge:  Deutsche  medizinische  Wochenschrift,  January  28,  1904,  XXX, 
p.  161. 

^  Baumgarten:  VerhancUungon  dor  doutschen  pathologischen  Gesoll.schaft, 
1905,  y,  p.  5;  Berhner  khnische  Wochenschrift,  October  8,  1906,  XLllI,  p. 
1333. 

'  Virchow:  Virchow's  Archiv  f.  path.  Anat.,  1902,  Band  167,  Heft  1,  p.  1. 


PRIMARY  LARYNGEAL  TUBERCULOSIS  313 

tubercle  of  cattle  and  of  man.  Into  the  enormous  literature, 
which  sprang  up  owing  to  Koch's  declaration  that  both  the  bacillus 
and  the  lesion  were  different  and  had  little  to  do  with  one  another 
in  cattle  and  man,  I  cannot  go.  I  may,  however,  refer  to  the 
recent  work  of  Park  and  Krumwiede,^  in  which  they  demonstrate 
that  although  the  tubercle  bacillus  of  cattle  rarely  causes  fatal 
lesion  in  adult  man,  it  is  the  cause  of  tuberculosis  affecting  children 
in  a  considerable  proportion  of  the  cases. 

Chiari,"  in  1899,  expressed  the  belief  that  not  only  did  primary 
tuberculosis  occur  in  the  upper  air  passages,  but  that  direct  pul- 
monary infection  by  inhalation  was  rare,  and  that  secondary 
systemic  infection  from  primary  lesions  in  the  upper  air  passages 
by  deglutition  and  by  aspiration  to  the  gastro-intestinal  tract  and 
to  the  lungs  was  the  root  of  much  systemic  tuberculosis. 

The  question  as  to  whether  the  tubercle  bacillus  can  pass  through 
the  sound  epithelium  was  discussed  early  and  in  many  papers.^ 
Schech^  was  an  advocate  of  Baumgarten's  contention  that  after 
the  bacillus  had  passed  there  was,  as  a  rule,  formed  a  tuberculous 
lesion  beneath  the  epithelium.  Schech  was  also  a  believer  in  the 
passage  of  the  bacillus  directly  through  the  mucosa,  and  Wright,'^ 
as  early  as  1896,  showed  the  bacilli  in  the  surface  epithelium  of  a 
tuberculous  larvnx  distributed  in  such  a  wa\'  that  there  seemed 
no  doubt  that  they  were  passing  through  from  the  surface. 

Primary  Laryngeal  Tuberculosis. — In  connection  with  this  also  the 
question  of  the  occurrence  of  primary  tuberculosis  was  often  the  sub- 
ject of  discussion,  but  the  question  was  a  matter  difficult  to  settle, 
inasmuch  as  patients  rarely  died  so  long  as  the  tuberculous  lesion 
was  confined  to  its  apparent  origin  in  the  upper  passages.  The 
matter  was  discussed  by  Bernheim,'^  Jouane,^  Gleitsmann,"^  while 
Hedinger^  demonstrated  the  phenomenon  at  postmortem  examina- 
tion in  which  a  tuberculous  lesion  was  shown  in  the  trachea  and 
bronchi  of  a  patient  who  showed  no  other  tuberculous  lesions  else- 
where in  the  body.    V.  Hansemann  and  Schmorl  had  seen  other  cases. 

On  the  whole,  however,  the  evidence  was  insuflficient  to  account 
for  all  cases  of  systemic  tuberculous  infection  bv  assuming  that  the 
bacilli  are  absorbed  from  the  surfaces  of  the  upper  air  passages. 

1  Park  and  Krumwiede:  Journal  of  Medical  Research,  1910,  XXIII,  2,  p.  205' 

2  Chiari:  Berliner  klinische  Wochenschrift,  Nos.  45-47,  1899,  XXXVI,  pp. 
984,  1007,  1035. 

3  E.  Fracnkol:  Virchow's  Archiv  f.  path.  Anat.,  1890,  Band  121,  p., 523. 
Bollinger;  Miinchener  medizinische  Wochenschrift,  1890,  No.  33,  XXXVII, 
p.  567.  Kafemann:  BehantUung  der  Larynxphthise,  Deutsche  medicinische 
Wochenschrift,  1889,  XV,  p.  370. 

*  Schech:  Heymann's  Handbuch,  1898,  I,  2  hiilfte,  p.  1109. 

*  Weight:  New  York  Medical  Journal,  September  26,  1896,  LXIV,  p.  412. 

^  Bernheim:   Rev.  nied.  suisse  roniande,   1900,  XX,  j).  501;  ref.,   Internat. 
Centralblatt  fiir  Laryngologie,  1901,  X\'II,  p.  152. 
^  Jouane:  These  de  Toulouse,  1900. 

*  Gleitsmann:  The  Laryngoscope,  June,  1904,  XIV,  p.  431. 

'Hedinger:  Verhandlungen  der  palhologischen  Gesellschaft,  1904,  VII,  p. 
83;  Centralblatt  fiir  allgemcine  Pathologic  und  pathologischc  Anatomic,  1904, 
XV,  p.  538. 


314  TUBERCULOSIS  OF  THE   UPPER  AIR  PASSAGES 

Nor  was  this  materially  streiijithened  by  the  contention  of  Thost/ 
who  in  189"),  asserted  that  infection  finds  entrance  through  soln- 
tions  of  continnity  in  the  ej)ithelinm  of  the  surface  and  of  the 
gland  acini  and  ducts.  It  was  necessary  to  postulate  the  assumption 
that  bacilli  are  carried  by  the  food  into  the  gastro-intestinal 
tract  and  there  pass  the  epithelium,-  many  claiming  they  appear  in 
the  lymph  glands  before  they  set  up  recognizable  lesions  elsewhere.^ 

Recent  ideas  as  to  the  possiblity  that  there  is  a  reversed  action  of 
the  cilia  of  the  gastro-intestinal  and  respiratory  tracts  under  certain 
conditions  have  done  much  to  give  a  priori  })lausibility  to  much 
that  seemed  contradictory  in  the  experimental  and  clinical  evidence. 
The  idea  that  the  bacilli  are  deposited  on  distant  surfaces  necessi- 
tated the  assumption  that  they  are  carried  to  the  lungs  either  in 
the  lymph  stream  or  the  ))lood  stream.^  Recent  in\'estigations 
have  rather  invalidated  the  idea  of  their  being  carried  in  the 
lymph  stream  accounting  for  the  distant  transport  of  infection,  but 
as  observers  have  depended  largely  upon  anatomical  investigations 
(among  these  I  have  referred  to  Beitzke's  work),  for  this  conclusion, 
the  matter  cam)ot  be  considered  as  settled. 

Nasal  Tuberculosis. — Yirchow^  had  noted  the  occurrence  post- 
mortem of  nasal  tuberculosis.  Willigk  had  also  observed  it  and 
in  1877  Laveran  had  spoken  of  a  case  of  a  nasal  lesion  he  had 
observed  which  he  supposed  was  tubercular,  but  Riedel  seems  to 
have  been  the  first  to  report*^  well-authenticated  cases.  Later 
Tornwaldt   reported'   a  case,    and   \Yeichselbaum    advanced^  the 

1  Thost:  Monatssohrift  fiir  Ohrenheilkundc,  1895,  No.  2,  XXIX,  p.  39. 
^  It  is  quite  impossible  to  cite  anything  but  a  modicum  of  the  enormous 
Hterature  on  this  subject.  In  addition  to  those  ah-eady  mentioned  see  For 
passage  through  the  intact  ?nucosa:  Cornet  and  Kossel:  Kolle  and  Wassermann, 
Handbuch  der  pathogenen  mikroorganismen,  2  Aufl.,  Band  V,  1912,  p.  391 
(.see  his  bibhography).  Hilgei'mann:  Archiv  fiir  Hygiene,  1905,  LIV,  p.  335. 
Uffenhcimer :  Deutsche  medizinische  Wochenschrift,  No.  46,  1906,  XXXII,  p. 
1851.  Plate:  Archiv  fiir  A\iss.  u.  prakt.  Tierheilk.,  1906,  XXXII,  p.  186. 
Orth  and  Rabinowitsch:  Virchow's  Archiv,  1908,  Band  194,  Beihefte,  p.  305. 
Orth:  Lehrbuch  der  speciellen  pathologischen  Anatomie,  Berlin,  1887.  -Wese- 
ner:  Kritische  und  experim.  Beitrage  zur  Lehre  von  der  Fiitterungstuberkulose, 
Freiburg,  1885.  liaumgarten:  Berliner  klinische  Wochenschrift,  1S99,  XXXVI, 
893;  1900,  XXXVII,  j).  136;  1901,  XXXVIII,  pp.  894,  1101,  1136,  1161;  1905, 
XLII,  p.  1329.  V.  Behring:  Deutsche  medizinische  Wochenschrift,  1903, 
XXIX,  p.  689;  1904,  XXX,  p.  193.  Ai-loing:  Compt.  rend.  Soc.  Biol.  1903, 
LV,  p.  480.  Against  passage  through  somul  mucosa:  Takeya  and  Dodd:  Arbci- 
ten  aus  der  path.  Inst.  Tiibingen,  Band  6,  710.  De  Vecchi:  Centralblatt  fiir 
allgemeine  Pathologic,  1909,  XX,  p.  786.  Klimenko:  Zeitschrift  fiir  Hygiene, 
1904,  XLVIII,  p.  67. 

'  Bartel:  1.  c.  Korvacs:  Ziegler's  Beitrage,  1907,  XL,  p.  281.  Plate:  1.  c. 
Hermann:  6  Internat.  Tuberculose  Konferenz,  Wien,  1907,  Bericht,  p.  103. 

*  The  literature  on  this  subject  cannot  be  given  further  here.  I  can  only 
refer  in  addition  to  (>arly  laryngological  ])apers  by:  lieschorner:  Die  locale 
Behandlung  der  KehlkoptVciiwiiidsucht,  1888.  Pfeiffer:  Zur  Bchandlung 
der  Kehlkopf  und  Lungcntuberkulose,  Leipzig,  1890.  Krieg:  Medizinisches 
Corre.spondenzljlatt,  1894,  No.  32,  LXIV,  p.  249. 

*  Virchow:  Die  krankhaften  Geschwulste,  1864-5,  II,  p.  651. 
^  Riedel:  Deutsche  Zeitsch.  f.  Chirurgie,  1878,  X,  p.  56. 

'  Tornwaldt:  Deutsches  Arch.  f.  klin.  Med.,  1880,  XXVII,  p.  586. 
8  Weichselbaum:  Allg.  Wien.  med.  Ztg.,  18S1,  No.  27,  XXVI,  p.  268. 


TREATMENT  OF  TUBERCULOUS  LARYNGITIS  315 

assertion,  thus  far  unsupported,  that  the  severe  form  of  what  he 
called  scrofulous  ozjena  is  dependent  on  miliary  tubercle.  He  also 
pointed  out  the  rarity  of  these  cases.  Cartaz/  Schaeffer,-  and 
Bresgen^  reported  a  number  of  cases  in  1887. 

Treatment  of  Tuberculous  Laryngitis. — In  the  seventeenth  century 
Marcellus  Donatus*  refuted  the  declaration  of  Galen  that  ulcers 
of  the  arteria  aspera  are  easily  cured. 

In  the  treatment  of  tuberculous  laryngitis  it  would  be  no  exaggera- 
tion to  say  that  almost  ever}-  drug  which  can  be  volatilized  or 
dissolved  and  used  as  a  spray  has  been  used.^  Applications  and 
submucous  injections  of  lactic  acid,  iodoform,  and  creosote  were 
initiated  by  Heryng  and  Krause  while  the  employment  by  them 
and  others  of  scarifications,  curettage,  morcellement  prevailed 
as  routine  methods  until  recent  ,years.  The  more  exceptional 
methods  of  galvanocauterization,*^  electrolysis,'  tracheotomy,^  thy- 
rotomy,'^  even  extirpation  of  the  larynx^"  all  had  their  advocates, 
with  reports  of  an  imposing  array  of  cures.  Tuberculin  was  used 
after  its  efficiency  in  the  general  treatment  was  announced  by 
Koch  in  1890  and  it  has  been  employed  ever  since,  though  a  brilliant 
review  of  results  by  Semon'^  promptly  called  its  value  into  question. 
Intratracheal  injections,^^  sunlight,^^  and  Rontgen  rays^*  must  not  be 
forgotten  in  the  enumeration. 

Notwithstanding  this  imposing  array  of  therapeutic  measures, 
most  of  them  supported  by  results  attained  by  the  reporter  which 
no  one  else  could  secure,  the  general  consensus  of  opinion  as  to  the 

1  Cartaz:  La  France  medicale,  1887,  No.  84,  XXXIV,  p.  1007. 

2  Schaeffer:  Deutsche  medizin.  Woch.,  1887,  No.  15,  XIII,  p.  .307. 
'  Bresgen:  Deutsche  medizin.  Woch.,  1887,  No.  30,  XIII,  p.  663. 

*  Donatus:  De  Historia  Medica  Mirabih  Lib.,  Francofurti  a.  M.,  1613,  III, 
Cap.  I. 

^  For  an  extensive  bibliography  upon  this  and  other  points  in  the  therapy  of 
larjTigeal  tuberculosis  see  Schech:  Heymann's  Handbuch,  Wien,  1898,  I,  2 
halfte,  p.  1109. 

*  Grtinwald:  Mlinchener  medizinische  Wochenschrift,  1903,  No.  25,  L,  p. 
1069.    Krieg:  Archiv  fur  Laryngologie  und  Rhinologie,  1904,  XVI,  p.  288. 

'  Tovolgyi:  Ref.,  Internal.  Centralbh^tt  flir  Laryngologie,  1904,  XX,  p.  354. 
Baumgarten:  1.  c. 

*  Moritz  Schmidt:  Die  Krankheiten  der  oberen  Luftwege,  Berlin,  1894. 
Gaudier:  Echo  Med.  du  Nord,  June  12,  1904,  VIII,  p.  283.  Henriei:  Mlinch- 
ener medizinische  Wochenschrift,  1904,  No.  1,  LI,  p.  43;  Archiv  flir  Laryn- 
gologie und  Rhinologie,  1904,  XV,  p.  323;    1906,  XVIII,  p.  88. 

^  Goris:  Ref.,  Internat.  Centralblatt  fiir  Laryngologie,  1905,  XXI,  p.  79. 
Stein:  The  Laryngoscope,  October,  1904,  XIV,  p.  777. 

'"Gluck:  Extirpation  of  Tongue,  Larynx,  etc.,  Internat.  Centralblatt  fiir 
Laryngologie,  1906,  XXII,  p.  475;  Internat.  Centralblatt  fur  Laryngologie, 
1907,  XXIII,  p.  114.  Barwell:  Epiglottidectomj^,  Internat.  Centralblatt  fur 
Laryngologie,  1907,  XXIII,  p.  76;  The  Lancet,  November  10,  1906,  II,  p.  1277. 

"  Semon:  Internat.  Centralblatt  fiir  Laryngologie,  1891,  VIII,  p.  223. 

"  Sorgo:  Wiener  medizinische  Wochenschrift,  1905,  No.  5,  LV,  p.  246.  Baer: 
Wiener  klinische  Woch(>nschrift,  1906,  No.  10,  XIX,  p.  271. 

"  Kramer:  Archiv  fiir  Laryngologie  und  Rhinologie,  1909,  XXI,  Ileft  3,  p. 
519.  Nepveu:  Bulletin  de  I'Academie  de  Mcdecine,  October  19,  1909,  3  s4r., 
LXII,  p.  197. 

'^  Winkler:  Internat.  Centralblatt  fiir  Laryngologie,  1905,  XXI,  p.  457. 


316  TUBERCULOSIS  OF  THE   UPPER  AIR  PASSAGES 

curability  of  laryiifjeal  ])htliisis  was  most  pessimistic.  Kiittiier,' 
ill  1902,  drew  attention  to  the  evil  inHnence  of  ])re,<'naney  npon  the 
course  of  the  afl'ection,  and  his  observations  were  quickly  confirmed 
by  many  others.  Although,  in  1880,  tuberculosis  of  the  larynx- 
was  regarded  as  incurable  and  although  for  many  years  this  was 
the  expressed  opinion  of  a  respectable  number  and  the  tacit  opinion 
of  the  majority  of  laryngologists,  numerous  bona  fide  reiK)rts  of 
its  cure  may  be  found  e^■en  in  the  comparatively  early  days  of 
the  institution  of  active  treatment.  By  1898  Schecli  (1,  c.)  cited 
numerous  instances  of  it.^  As  a  matter  of  fact  even  cases  of  spon- 
taneous healing  had  been  noted  by  Stork^  before  1880  and  since 
1898  by  Xemai.^  Bergengrinv^  was  among  the  first  to  avow  the 
futility  of  local  treatment  alone  and  the  frequent  efficacy  of  modern 
general  therapy  in  the  cure  of  local  lesions.  It  was  in  190()  that 
Semon"  first  emphasized  in  numerous  papers  the  value  of  absolute 
silence  and  rest  of  the  larynx  in  the  treatment  of  laryngeal  phthisis. 
Other  communications  by  Luc,^  Lublinski,^  and  others  haxe  con- 
firmed it,  and  it  may  be  safely  said  tliat  at  present  every  other  form 
of  local  therapy  combines  this  with  it  and  with  that  of  a  general 
systemic  and  hygienic  regime,  and  that  this  has  done  much  to 
banish  the  pessimism  and  hopelessness  with  which  laryngologists, 
as  a  rule,  formerly  viewed  a  case  of  tuberculous  laryngitis.^ 

^  Kiittner:  Archiv  fiir  Laryngologie  unci  Rhinologie,  1902,  XII,  Heft  3,  p. 
311.  Berliner  klinische  Wochenschrift,  1905,  No.  29-30,  XLII,  pp.  901,  94.5; 
Monatsschrift  fiir  Ohrenhoilkunde,  1901,  No.  11,  XXXV,  p.  467.  Veis: 
Monatsschrift  fiir  Ohrenlieilkunde,  1902,  No.  4,  XXXVI,  p.  129.  Seifert: 
Die  Heilkunde,  1903,  No.  2,  VII,  p.  49.  Lohnberg:  Miinchener  medizinische 
Wochenschrift,  1903,  No.  8,  L,  328.  Godskesen:  Archiv  fiir  Laryngologie 
und  Rhinologie,  1903,  XIV,  Heft  2,  p.  286.  Lewy:  Archiv  fiir  Laryngologie 
und  Rhinologie,  1904,  XV,  Heft  1,  p.  114.  Levinger:  Miinchener  medizinische 
Wochenschrift,  1906,  No.  23,  LIII,  p.  1110. 

^  M.  Schmidt:  1.  c.  Laiienberg:  Miinchener  medizinische  Wochenschrift, 
1890,  No.  17,  XXXVII,  p.  304.  Przedborski:  Verhandl.  d.  X  Internationalen 
med.  Congresses,  1890,  IV,  abt.  12,  p.  147.  Krieg:  1.  c.  Bergengriin:  Archiv  fiir 
Laryngologie  und  Rhinologie,  1895,  II,  p.  153.  Thost:  1.  c.  Hajek:  Central- 
blatt  fiir  die  gesammtc  Therapie,  No.  2,  1895. 

'  Stork:  Klinik  der  I\j-ankheiten  des  Kchlkopfes,  ISSO. 

*  Nemai:  Internat.  Centralblatt  fiir  Laryngcjlogie  und  Rhinologie,  1901, 
XVII,  p.  496. 

*  Bergengriin :  St.  Petersburger  medizinische  Wochensclirift,  1902. 

^  Semon:  British  Medical  Journal,  1906,  II,  1623;  Medical  Record,  December 
15,  1906;  Berhner  klinische  Wochenschrift,  19()(),  No.  47,  XLIII,  p.  1498. 

'  Luc:  Rev.  gen.  de  Clin,  ct  de  Tlier.  .Journal  des  Practicicnis,  Februarj'  2, 
1907,  XXI,  I).  65. 

«  Lublinski:  Berliner  klijiische  Wochenschrift,  1906,  No.  52,  XLIII,  p.  1657. 

'  The  reader  may  be  referred  to  some  of  the  discussions  which  took  place 
from  time  to  time  in  lai-yngological  s()ci(>ties  in  order  to  api)reciale  this,  and  to 
monographs  on  the  subject,  some  of  which  did  not  partake  of  this  somber  view 
of  the  matter;  British  Medical  Association,  1901-1905,  Internat.  Centralblatt 
fur  Laryngologie,  J903,  XIX,  p.  34;  1906,  XXII,  p.  194.  Verein  westdeutscher 
Hals  und  Ohren  Aerzte,  December,  1902,  Internat.  Centralblatt  fiir  Laryn- 
gologie, 1904,  XX,  p.  52.  (Jriiinv.'dd:  Die  I'lierapie  der  Kehlkojiftuberculose 
mit  be.sonderer  Riicksicht  auf  den  galvanokaustisclicn  Tiefenstich  und  iiussere 
Eingriffe,  Miinchen,  1907.    Besold  antl  Cidionsen:  Pathologic  und  Therapie  der 


RHINOSCLEROMA  31' 


RHINOSCLEROMA. 


There  is  hardly  a  disease  of  the  upper  air  passages  which  presents 
those  fascinations  of  the  unknown  to  the  student  of  medicine  to 
the  degree  which  is  revealed  by  an  acquaintance  with  the  known 
facts  of  rhinoscleroma.  Sharply  confined  in  its  insidious  initial 
stages  to  persons  residing  in  a  limited  and  fairly  w^ell-defined 
geographical  region,  regularly  associated  with  a  bacillus  indis- 
tinguishable from  those  found  in  other  pathological  lesions  of  an 
entirely  different  nature  and  from  those  found  not  infrequently 
in  the  normal  upper  air  passages,  rhinoscleroma  has  baffled  epi- 
demiologist, bacteriologist  and  histologist  alike  in  the  searching 
inquiry  which  has  been  made  into  its  etiology. 

In  1870  Hebra^  first  described  the  condition  as  seen  in  the  nose, 
differentiating  it  from  the  tertiary  and  the  other  stages  of  syphilis. 
In  attempting  to  classify  it  on  a  histological  and  clinical  basis, 
Kaposi,"  in  1872,  regarded  it  as  belonging  to  the  granulosarcomata. 
In  the  same  year,  Geber^  placed  it  among  the  inflammatory  granu- 
lomata.  The  question  as  to  whether  it  belongs  to  the  subdivision 
of  infectious  granulomata  is  still  unsolved.  It  is  to  Mikulicz^  we 
owe  the  first  accurate  histological  description  in  187(3  of  the  forma- 
tion of  the  scar  tissue  and  the  identification  of  the  peculiar  path- 
ognomonic foam  or  lace-like  cells  to  which  his  name  has  been 
attached.  Notwithstanding  this,  he  conjectured  it  might  have 
some  connection  with  syphilis.  This,  Schmiedicke,^  in  1880,  defin- 
itely refuted.  Ganghofner,*^  in  1881,  referring  to  those  cases  in 
which  the  lesion  was  confined  to  the  larynx,  limited  the  name  to 
the  term  scleroma.  Frisch,^  in  1882,  and  Pellizzari,^  in  1883,  showed 
that  the  bacillus  w^as  constantly  present  in  the  foam  cells  and  in 
the  lymph  spaces;  this  was  confirmed  by  CorniP  in  a  memoir  of 
the  same  year  and  subsequently  in  1884  in  his  text-book.  Chiari 
and  Riehl,!^  in  1885,  more  fully  described  its  clinical  aspects.  In 
the  next  year  and  in  1887  many  articles  appeared  on  the  subject 
and  Bender^^  gave  an  historical  account  of  it  up  to  that  time. 

Kehlkopftuberculose,  Berlin,  1907.  Iinhofer:  Die  Geschichte  der  Kehlkopf- 
tubei'culose  vor  Erfindung  des  Kehlkopfspiegels:  Bresgen's  Sammlung  zwangl. 
Abh.  .  .  .  Nasen,  .  .  .  1908,  IX,  Heft  7-8.  Lockard:  Tuberculosis  of 
the  Nose  and  Throat,  St.  Louis,  1909. 

^  Hebra:  Wiener  medizinische  Wochenschrift,  1870,  XX,  p.  1. 

^  Kaposi:  Virchow's  spec.  Path,  und  Therap.,  1872,  III,  2,  p.  288. 

^  Geber:  Ai'chiv  fiir  Dermatologie,  1872,  IV,  p.  493. 

*  Mikuhcz:  Langenbeck's  x\rchiv  fiir  khnische  Chirurgie,  1876,  XX,  p.  485. 
'  Schmiedicke:    Vierteljahreschrift   fiir    Dermatologie    und    Syphilis,    1880, 

VII,  p.  2,57. 

^  Ganghofner:  Zeitschrift  fiir  Heilkunde,  1881,  II,  p.  400. 

'  Frisch:  Wiener  medizini.sche  Wochenschrift,  1882,  No.  32,  XXXII,  9G9. 

*  PeUizzari:  Ref.,  Vierteljahreschrift  fur  Dermatol,  und  Syph.,  1883,  X,  p.  07(3. 
^  Cornil:  Bull.  Soc.  Anatomic  de  Paris,  Progres  Med.,  1883,  XI,  p.  587. 

'n  Chiari  and  Riehl:  Zeitscihrift  ffu-  Heilkunde,  1885,  VI,  p.  305. 
"  Bender:  Centralblatt  fur  Bakteriologie,  1887,  I,  p.  503. 


318  RHINOSCLEROMA 

Paltauf  and  Eiselsberg/  Coriiil,^  Babes,''  and  Doutrelepont^  made 
more  elaborate  bacteriological  studies  whereby  the  bacillus,  now 
called  the  Frisch  bacillus,  was  ])erceiv(Ml  to  l)e  closely  related  if 
not  identical  with  the  Friedliinder  bacillus,  and  the  discussion  as 
to  the  nature  of  the  hyaline  bodies  was  initiated  l)y  these  authors, 
Dittrich^  and  IMibclli*'  also  describing  them  in  1889.  Abel,'  in 
1893,  in  bacteriological  investigations  of  ozsena  drew  attention  to 
the  similarity  of  a  bacillus  found  by  him  in  that  disease  with  the 
bacilli  of  Frisch  and  Friedlaender.  Dittrich  and  Bahes  both  doubted 
the  specificity  of  the  rhinoscleroma  bacillus.  De  Simoni,^  in  1889, 
inoculated  the  nasal  mucosa  of  a  phthisical  patient  with  the 
bacillus  without  producing  the  lesion,  and  found  the  bacillus  in 
normal  air  passages.  V.  Schroetter,^  in  1901,  inoculated  himself 
in  the  arm  with  a  piece  cut  from  a  scleromatous  lesion  with  no 
result  but  the  production  of  a  tedious  abscess.  Hence  Streitj^"  who 
in  1907  furnished  a  good  history  of  the  literature,  concluded  from 
these  and  his  own  investigations  that  the  specificity  of  the  bacillus 
was  not  proved.  In  spite  of  elaborate  work  by  Streit  and  others 
since  then  neither  morphologically  nor  by  culture,  nor  by  various 
serological  tests,  has  it  been  differentiated  from  the  bacilli  mentioned 
above.  Its  geographical  limitation  was  at  first  a  matter  of  secondary 
interest,  but  in  1900,  Gerberi^  showed  its  peculiar  distribution  in 
Prussia,  discussed  also  by  Streit^^  in  1903.  jNIayer^^  described  foci 
of  the  disease  in  Austria  and  Hungary  in  1906.  All  spoke  of  it 
as  existing  in  Russia.  These  foci  were  in  proximity  to  and  lying 
around  and  between  the  Baltic  and  Black  Seas.  Cases  have  been 
described  as  originating  in  Switzerland  and  in  Egypt  by  Mermod" 
and  Kornfeld.^^ 

In  the  references  gi^'en  above,  copious  remarks  may  be  found 
as  to  the  treatment  of  the  affection.     In  addition  it  ma^'  be  said 

1  Paltauf  and  Eiselsberg:  Fortschritte  der  Medizin,  1886,  IV,  p.  617.  Paltauf: 
Centralblatt  fur  Bakt.,  1887,  No.  8,  I,  p.  236. 

2  Cornil:  Progres  Med.,  1883,  XI,  p.  .587. 

•■*  Babes:  Centralblatt  fiir  Bakteriologie,  1887,  No.  21,  II,  p.  617. 

^  Doutrclepont:  Deutsche  medizinische  Wochcnschrift,  1887,  XIII,  p.  85. 

'Dittrich:  Zeits.  fiir  Ileilkunde,  1887,  VIII,  p.  251;  ref.,  Centralblatt  fiir 
Bakteriologie,  1887,  No.  14,  II,  p.  88. 

•5  MibelU:  Centralblatt  fur  Bakteriologie,  Janutiry  25,  1889,  No.  5,  V, 
p.  177. 

7  Abel:  Centralblatt  fiir  Bakteriologie,  1893,  XIII,  p.  161. 

8  De  Hinioni:  Centralblatt  fur  Bakt(>riologie,  1899,  1  Abt.,  XXV,  p.  625. 

'  V.  Schi-oetter:  Benierkungen  iiber  die  Bedeutung  eines  systematischen 
Studium  dcs  Skleroms,  Klinisches  .Jahrb.,  1901,  VIII,  p.  297. 

1"  Streit:  Archiv  fiir  Laryngologie,  1907,  XIX,  p.  408. 

"  Gerber:  Archiv  fiir  L.aryngologie,  1900,  X,  p.  347;  1904,  XVI,  p.  176. 
Baurowicz:  Archiv  fiir  Laryngologie,  1900,  X,  p.  363,  described  100  cases. 

12  Streit:  Archiv  fiir  Laryngologie,  1903,  XIV,  p.  257;  1904,  XVI,  p.  407. 

"  Mayer:  Archiv  fiir  Laryngologie,  1906,  XVIII,  p.  428. 

"  Mermod:  Rondaeff.  Contribution  a  I'etude  du  rhinosclerome  en  Suisse, 
These  de  Lausanne,  1905.  ■ 

'6  Kornfeld:  Monatsschrift  fiir  Ohrenhcilkunde,  Berk,  1905,  XXXIX,  p.  404. 


AU  TOSCO  PY  319 

that  Fittifj,!  Schein,^  and  ]Mayer^  have  treated  the  disease  with  the 
a;-rays  and  Giintzer^  with  vaccines.  Notwithstanding  the  usual 
optimism  disphiyed  in  all  therapeutical  literature  there  is  nothing 
to  convince  the  skeptical  that  any  curative  results  have  been 
attained.  In  1911  Wright  and  Strong^  reported  the  presence  in 
great  abundance  of  particles  reacting  to  the  soap  stain  in  the  foam 
cells  and  the  degenerated  areas  of  the  lesion  and  upon  the  dis- 
tribution in  general  of  fats  and  lipoids.  They  also  reported  some 
work  done  with  complement  fixation  in  criticism  of  previous  work 
by  Goldzieher  and  Xeuber'^  w^ho  believed  by  this  method  they  were 
able  to  distinguish  the  Frisch  from  the  Friedlaender  bacilli. 

Autoscopy. — Kussmaul,  in  1868,  is  said^  to  have  been  the  first  to 
make  a  direct  intra  vitain  examination  of  the  oesophagus.  He 
employed  an  urethroscope  which  had  been  invented  by  Desormeaux. 
This  was  practised  by  several  others  before  Kirstein  and  Killian 
applied  it  to  the  larynx.  Kussmaul  was  enabled  to  do  this  with 
greater  ease  because  he  had  as  a  means  of  demonstration  the 
services  of  a  sword  swallower.  In  1895  Kirstein^  demonstrated  a 
technique  by  which,  with  the  head  extended  and  the  epiglottis  and 
tongue  depressed,  it  was  possible  to  make  a  direct  inspection  of  the 
larynx,  which  procedure  he  designated  under  the  name  of  autoscopy. 
JNIikulicz,^  Killian,  Cowl,^°  and  others  quickly  took  the  matter  up. 
Killian  is  said^^  to  have  been  the  first  to  have  removed  a  bone  from 
the  larvnx  b^'  the  Kirstein  method.  Although  von  Hacker^-  seems  to 
have  been  the  first,  in  1902,  to  insert  a  rigid  tube  into  the  trachea  and 
thus  to  have  practised  tracheoscopy,  Killian  and  Chevalier  Jackson^^ 
and  many  others  since  have  developed  the  technique  of  introducing 

1  Fittig:  Beitriige  zur  klin.  Chirug.,  Tubingen,  1903,  XXXIX,  pp.  15.5-161. 

^  Schein:  Ungar  med.  Presse,  1905,  X,  p.  101;  Pest.  med.  chii-.  Presse,  Buda- 
pest, 1905,  XLI,  p.  6.38. 

3  Alaver:  Berl.  klinische  Wochenschrift,  1906,  XLIII,  jip.  U64,  1638. 

*  Giintzer:  Medical  Record,  July  24,  1909,  LXXVI,  p.  129.  See  this  last 
reference  for  the  best  account  of  the  disease  in  the  Enghsh  language  and  for  a 
full  bibliography.  For  further  information  as  to  the  more  recent  work  upon 
rhinoscleroma  see  Babes,  Kolle,  and  Wassermann:  Hand.  d.  path.  Mikroorg., 
zweite  aufl.,  1913,  Band  V,  p.  1237. 

^  Wright  and  Strong:  New  York  Medical  Journal,  March  18,  1911,  XCIII, 
p.  517. 

^  Goldzieher  and  Neuber:  Centralblatt  ftir  Bakteriologie,  1909,  Orig.,  LI,  p. 
121. 

'  Killian:  Geschichte  der  Oesophago-  und  Gastroskopie,  Deutsche  Zeitschrift 
fiir  Chirurgie,  1900-01,  LVIII,  p.  499. 

^  Kirstein:  Archiv  f.  Laryngologie  und  Rhinologie,  1895,  III,  p.  150;  1897, 
VI,  p.  482. 

^  Mikulicz:  Die  Autoskopie  des  Kehlkopfes  und  der  Luftwege,  1896. 

1"  Cowl:  Archiv  f.  Laryngologie  und  Rhinologie,  1898,  VII,  p.  478. 

'1  KoUofrath:  Miinchener  medizinische  Wochenschrift,  September  21,  1897, 
No.  38,  XLIV,  p.  1038. 

1-  Von  Hacker:  Deutsche  medizinische  Wochenschrift,  1905,  No.  39,  XXXI, 
p.  1535. 

'^  Jackson;  Tracheobronchoscopy,  The  Laryngoscope,  1907,  XVII,  pp.  492, 
785.  Von  Kicken:  Archiv  f.  Larj'ngologie  und  Rhinologie,  1904,  XV,  p.  375. 
Von  Brimings:  Die  directe  Laryngoskojjie  und  Oesophagoskopic,  1910. 


320  LARYNGEAL  PARALYSIS 

tracheal  and  l)ronehial  tubes  into  the  air  passages  for  diagnostic 
and  operative  purposes.  INIost  recently  Killian'  has  published  a 
method  in  which,  by  ingenious  adaptations  and  inventions,  he 
has  succeeded  in  supporting  the  tube  while  in  place  in  the  air 
passages  in  such  a  manner  that  both  hands  of  the  operator  are 
free  to  use  in  manipulations  upon  those  parts  exposed  in  the  field 
of  vision.  To  this  technique  he  has  given  the  name  of  "Schwebe- 
laryngoskopie." 

These  methods  of  direct  inspection  and  operation  u})on  the 
larynx  and  lower  air  tubes  by  means  of  it  are  epoch-making  advances 
in  laryngology  and  have  rendered  possible  the  execution  of  pro- 
cedures which  before  could  not  have  been  accomplished  by  any 
possible  means.  In  combination  with  the  achievements  of  rontgen- 
ology many  li\'es  have  been  saved  in  this  way  that  were  hitherto  lost. 

LARYNGEAL  PARALYSIS  AND  THE  INNERVATION 
OF  THE  LARYNX. 

The  First  Reports. — ^Yhile  the  literature  of  the  innervation  of 
the  larynx  goes  back  to  Galen,  and  of  this  we  have  given  some 
account,  the  history  of  laryngeal  paralj'sis  can  hardly  be  pursued 
with  much  profit  in  the  prelaryngoscopic  era.  According  to  Semon,^ 
Traube  was  the  first  to  give  an  account^  of  the  laryngoscopic  image 
in  a  case  of  laryngeal  paralysis.  The  condition  was  due  to  pressure 
of  a  thoracic  aneurysm  on  the  recurrents,  but  the  diagnosis  of  the 
lesion  in  the  chest  was  not  made  at  such  an  early  date  as  this  by 
means  of  the  laryngoscope,  which  in  later  years  has  become  so 
\alual)le  an  adjuvant  to  other  methods  of  physical  diagnosis  in 
the  differentiation  of  the  condition. 

Turck  declared^  that  in  1859  he  had  already  reported  a  case, 
but  the  interpretation  of  his  reference  leaves  the  matter  in  some 
doubt,  though  in  the  next  year  he  described^  immobility  of  the 
left  vocal  cord  in  a  case  of  right  hemiplegia.  Lewin  in  the  same 
year  gave  a  good  description*^  of  paresis  of  the  muscle  of  the  right 
arytenoid  cartilage,  "which  narrows  the  glottis,  and  does  not  pro- 
duce hoarseness,"  in  a  patient  suffering  from  constitutional  syphilis, 
evidently  a  case  of  posticus  paralysis.    Mandl  gave  an  early  but 

1  Killian:  Archiv  f.  Laryngologie  und  Rhinologie,  1912,  XXVI,  p.  277. 

^  Semon:  The  Study  of  Laryngeal  Paralysis  since  the  Introduction  of  the 
Laryngoscope.  For  a  fuller  account  of  the  subject  see  this  exhaustive  bibhog- 
raphy.  See  also  the  review  of  the  subject  by  Wright,  Two  Cases  of  Larvngcal 
Paralysis,  N.  Y.  Med.  Jour.,  September  28,  1889,  L,  p.  345.  The  literature  of 
the  subject  may  be  also  studied  in  a  monograph  by  Burger:  The  Laryngeal 
troubles  of  Tabes  Dorsalis,  1891. 

'  Munk:  Laryngoskopischer  Befund  in  einem  Fall  von  Aneurysma  des  Arcus 
Aortae,  Deutsche  Klinik,  18()1,  No.  27,  XIII,  p.  2()3. 

*  Tiirck:  Klinik  der  Ivi-ankheiten  des  Kehlkopfes,  etc.,  1866,  p.  443. 

'  Allg.  Wien.  med.  Ztg.,  1860,  No.  9,  V,  p.  67. 

«  Lewin:  Ref.,  Schmidt's  Jahrb.,  1860,  CVIII,  p.  99. 


CADAVERIC  POSITION  321 

rather  confused  account  of  the  subject  in  France/  and  reported  a 
number  of  poorly  differentiated  cases,  including,  however,  some  of 
functional  disturbances. 

Differentiation. — We  find  him  using  the  term  laryngeal  epilepsy, 
but  not  in  the  sense  subsequently  employed  by  Charcot.  Tiirck,- 
we  may  note,  interpreted  a  case  of  what  was  apparently  hysterical 
aphonia  as  spasm  of  the  cricothyroid  muscles.  Gerhardt^  was 
the  first  to  begin  the  intelligent  differentiation  of  laryngeal  paralysis 
according  to  the  lesions.  Biiumler^  and  Johnson^  showed  that  a 
unilateral  affection  of  the  vagus  may,  under  certain  circumstances, 
produce  a  bilateral  paralysis  of  the  vocal  cords,  or  paralysis  on  one 
side  and  spasm,  as  he  believed,  on  the  other.  In  America,  in  1869, 
F.  I.  Knight  reported''  three  cases  of  lar^'ngeal  paralysis.  At  first 
cases  of  functional  paralysis,  chiefly  hysterical,  were  confounded 
with  those  of  an  essential  lesion,  as  we  have  noted  in  the  reports 
of  ]Mandl  and  Tiirck,  and  there  is  consequently  much  confusion 
in  the  earlier  papers  on  the  subject,  as  for  instance  those  of  jNIac- 
kenzie'^  and  Cohen.^ 

"  Cadaveric  Position." — In  1870  Gerhardt  contributed  another 
valuable  paper^  to  the  literature  of  the  subject,  in  which  he  intro- 
duced the  term  "cadaveric"  position  of  the  vocal  cord,  to  indicate 
its  situation  in  total  laryngeal  paralysis,  a  term  to  which  of  late 
there  has  justly  been  made  objection  as  being  inaccurate.  This 
paper  much  advanced  the  clinical  knowledge  of  the  subject.  In 
the  same  year  appeared  another  important  paper^°  by  Riegel,  who 
pointed  out  the  distinction  between  respiratory  and  phonatory 
paralysis. 

Schech^^  and  Schmidt^'-  did  much  to  formulate  the  arrangement 
of  laryngeal  innervation  and  muscular  movements  given  by  the 
text-books,  and  accepted  up  to  the  date  of  the  Rosenbach-Semon 
"law"  and  the  Krause  controversy  as  to  the  nature  of  the  cases 
of  median  position  of  the  cord.     W.  W.  Keen,^^  in  1875,  performed 

1  Mandl:  Des  Neuroses  Chroniques  du  Larynx:  Gaz.  des  Hopitaux,  1861, 
No.  4,  XXXIV,  p.  13. 

2  Tiirck:  Allg.  ^Yien.  medizin  Ztg.,  1862,  No.  8,  VII,  p.  70. 

3  Gerhardt:  Virchow's  Archiv  f.  path.  Anat.,  1863,  XXVII,  pp.  68,  296. 

*  Baumler:  Deutsches  Archiv  f.  Idin.  INIed.,  1867,  No.  6,  II,  p.  550;  Trans. 
Path.  Soc.  London,  1872,  XXIII,  p.  66. 

5  Johnson:  Trans.  Path.  Soc.  London,  1873,  XXIV,  p.  42. 

^  Knight:  Boston  Medical  and  Surgical  Journal,  February  25,  1869,  LXXX, 
p.  49. 

^  Mackenzie:  Hoarseness,  Loss  of  Voice  and  Stridulous  Breathing  in  Relation 
to  Nerve  and  Muscle  Affections  of  the  Larynx,  1868. 

8  Cohen:  Diseases  of  the  Throat  and  Nasal  Passages,  2d  Edit.,  1879. 

^  Gerhardt:  Ueber  Diagnose  und  Behandlung  der  Stimmbandliihrnung, 
Volkmann's  Sammlung  klin.  Vortriigo,   No.  36   (Inn.  Medizin,  No.  13),  1872. 

'"  Riegel:  Ueber  respiratorische  Paralj-sen,  Volkmann's  Vortrage,  No.  95 
(Inn.  Medizin,  No.  33),  1875. 

"  Schech:  Bcrl.  klin  Woch.,  1873,  No.  20,  X,  p.  234. 

12  Schmidt:  Ibid.,  1873,  No.  3,  X,  p.  32. 

'3  Keen:  Trans.  Coll.  of  Phys.  of  Philadelphia,  1875,  3  ser.,  I,  p.  97. 
21 


322  LARYNGEAL  PARALYSIS 

some  experiments  by  faradization  of  the  recurrent  laryngeal  ner^•es 
in  a  recently  hanged  man.  Notwithstanding  the  attention  which 
had  been  given  to  the  matter,  our  knowledge  of  the  subject  was 
still  in  a  very  unsatisfactory  state  for  many  years  after  the  laryngo- 
scope had   made  observers  familiar  with   tlie  local   appearances. 

Greater  Proclivity  of  Abductors  to  Paralysis. — Such  an  eminent 
authority  as  Stork  had,  as  late  as  J^S^U,'  declared  that  paralysis 
of  the  postici  muscles  was  one  of  the  rarest  of  laryngeal  neuroses. 
Some  cases  had  been  reported  previously  by  von  Ziemssen,  Bos- 
worth,  and  others,  but  the  subject  of  bilateral  paralysis  of  the 
abductors  was  more  carefully  described  in  187S  by  Semon.-  He 
pointed  out  in  the  German  edition  of  INIorell  IMackenzie's  book 
(1880),  in  a  footnote,  the  greater  proclivity  of  the  abductor  fila- 
ments of  the  recurrent  nerve  to  injury  from  disease  or  trauma.  This 
was  further  elaborated  by  him  in  a  paper  published^  in  1881. 
About  the  same  time  Rosenbach'*  drew  attention  to  the  same 
phenomenon.  They  established  the  fact,  which  has  been  occasion- 
ally known  as  Semon's  "law,"  that  when  one  laryngeal  muscle 
alone  is  affected  it  is  usually  the  abductor,  the  crico-arytenoideus 
posticus.  The  experimental  results  of  Onodi  and  Risien  Russell 
later  confirmed  this  in  animals. 

About  this  time  Elsberg^  noted  that,  although  other  muscular 
groups  may  recover  with  varying  rapidity  and  completeness  from 
paralysis,  the  pow-er  of  the  laryngeal  muscles  rarely  returns. 

The  Contracture  Theory. — Krause^  attempted  to  invalidate  the 
conclusions  of  Semon  by  advancing  his  theory  of  contracture. 
Many  subsequent  writers  accepted  the  aIcws  of  Krause.  They 
claimed  the  contracture  either  with  or  without  paralysis  of  the 
abductors  was  due  to  stimuli  of  various  kinds,  irritating  either 
the  nerve  trunks  or  their  cerebral  centres.  This  idea  had  been 
advanced  by  Jelenefiy^  in  1872,  and  was  further  elaborated  by  him 
in  1888.  In  1875  Johnson*  had  advanced  an  explanation  to 
account  for  bilateral  paralysis,  due  to  pressure  on  one  recurrent 
alone,  which  he  belie\'ed  was  due  to  ascending  degeneration  and 
involvement  of  the  chiasm  in  the  brain. 

A  vast  amount  of  experimentation  upon  animals  revealed  varia- 
tions in  the  effects  produced  by  different  strengths  of  the  electric 
current  applied  to  the  recurrent  nerve.  These  effects  varied  also 
according  to  the  degree  of  anesthesia  produced.    These  observations 

1  Stork:  Klinik  der  Krankheiten  des  Kehlkopfes,, Stuttgart,  1880,  p.  380. 

2  Semon:  Trans,  of  the  Clin.  Soc.  of  London,  18/8,  XI,  p.  141  ff. 
^  Semon:  Archiv(>s  of  Laryngologj',  1881,  No.  'A,  II,  j).  107. 
^Rosenbach:  Brcslaucr  Aerztl.  Zeitschrift,  1880,  2,  3,  II,  pp.  14,  27. 
6  Elsberg:  Philadelphia  Med.  Times,  July  30,  1881,  XI,  p.  693. 

e  Krause:  Virchovv's  Arch.  f.  path.  Anat.,  1884,  XCVIII,  p.  294.  Ibid.,  1885, 
CII,  p.  301.    Archiv  f.  Anat.  und  Physiol.,  Physiol.  Abth.,  1884,  p.  566. 

'  Jeleneffy:  Berl.  klin.  Wodi.,  1888,  No.  26,  34  seq.,  XXV,  pp.  522,  680,  70S, 
728 

8  Trans.  Med  Chir.  Soc,  London,  1875,  Vol.  LVIII,  p.  29. 


THE  CENTRAL  INNERVATION  OF  THE  LARYNX        323 

were  brought  out  chiefly  in  the  papers  of  Donaldson^  and  Hooper.^ 
The  literature  of  the  subject  at  this  time  grew  to  great  propor- 
tions. The  most  important  of  the  contributions  which  combated 
the  views  of  Krause  were  perhaps  those  of  Semon  and  Horsley^ 
and  of  Risien  RusselL*  The  latter  showed  that  the  abductor  and 
adductor  filaments  existed  in  the  recurrent  nerves  each  as  separate 
bundles  of  fibers.    This  was  also  announced  by  Onodi. 

The  Central  Innervation  of  the  Larynx. — The  central  inner\'ation 
of  the  larynx  was  also  developed,  pari  passu,  with  the  controversy 
in  regard  to  the  phenomenon  of  posticus  paralysis.  While  Ferrier^ 
had  in  1876  made  some  allusion  to  the  phonatory  movements  of 
the  larynx  on  cerebral  excitation,  and  while  Duret''  had  noted 
that  the  destruction  of  a  convolution  in  front  of  and  below  the 
sigmoid  gyrus  abolished  the  power  of  barking  in  a  dog,  Krause's 
paper/  in  1884,  was  really  the  first  of  a  series  of  many  others, 
among  them  especially  that  of  Semon  and  Horsley  (1.  c),  which 
has  developed  our  knowledge  of  the  cerebral  centre  of  laryngeal 
inner^'ation. 

]\Iagendie  and  Longet  had  described  the  action  of  tlie  crico- 
thyroid muscle  as  the  tensor  of  the  vocal  cords  by  virtue  of  it 
pulling  the  thyroid  cartilage  downward  and  forward,  the  base  of 
the  arytenoid  cartilages  or  the  \'ocal  processes  resting  on  the 
cricoid  and  remaining  stationary.  In  1873  Jelenefty*  showed  that 
the  cricoid  cartilage  was  drawn  up  and  backward  carrying  the 
vocal  processes  with  it,  thus  reversing  the  work  of  jNIagendie.  In 
this,  Jelenefly  has  been  supported  by  practically  all  investigators 
since  then.  Exner'-'  described  in  the  dog  and  rabbit  a  median 
laryngeal  nerve  supplying  the  cricothyroid  muscle  gi\'en  off  by 
the  pharyngeal  branch  of  the  \'agus  nerve  and  attempted  to  trace 
out  its  analogue  in  man,  but  while  there  are  communications 
between  the  pharyngeal  plexus  and  the  laryngeal  ner\es,  this 
application  to  human  anatomy  has  not  received  support.  Until 
the  year  1850  both  laryngeal  nerves  were  looked  upon  as  mixed 
nerves,  but  their  physiology  has  been  more  accurately  worked 
out,  and  the  details  of  it  may  be  found  in  Onodi'°  (1901),  who  de- 
scribes exhaustively  the  modern  view.    This,  as  entertained  by  the 

1  Donaldson:  Am.  Jour.  Med.  Sc,  July,  ISSCi,  XCII,  p.  93. 

2  nooi)er:  New  York  Med.  Jour.,  July  4,  1SS.5,  XLII,  p.  2. 

3  Semon  and  Horsley:  Brit.  Med.  Jour.,  December  21,  1889,  II,  p.  1383. 
Phil.  Trans.  Royal  Soc.  London,  Vol.  V,  181. 

^  Russell:  ProecH'diuKs  of  Royal  Hoe.,  1892,  LI,  p.  102. 

6  Fcrrier:  The  Funetions  of  the  Brain,  N.  Y.,  1876. 

«  Duret:  l^tudes  Kxperimentales  et  Cliniques  sur  les  Traumatismes  Cere- 
braux,  Paris,  1S7S. 

^  Ivrause:  Ueber  die  Beziehuiis  dcr  Grosshirm-inde  zuiii  Ivclilkopf  luid 
Rachen,  Areh.  f.  .\na1oniie  and  Physiok)sie,  Physiol.  Abth.,  1SS4,  p.  2U3. 

8  Jelenef'fy:  Pfliiger's  Archiv  fiir  d.  {>;es.  I'liysiologie,  1873,  \TI,  p.  77. 

9  Exncr:  Die  Innervation  des  Kehlko])fes,  Sitzungsberichte  der  K.  K. 
Akad.  der  \Viss(>nseh.,  18S4,  LXXXIX,  p.  ()3. 

'"  Onodi:  D'w  Anatomie  und  Physiologic  der  Kehlkopfnerven,  Berlin,  1902. 


324  LARYNGEAL  PARALYSIS 

great  majority  of  iiuestigators,  is  to  the  effect  that  the  recurrent 
ner^•e  is  entirely  a  motor  nerve  containing  no  centripetal  fibers. 

With  the  observation  and  discussion  of  numerous  cases  of  the 
immobility  of  the  cords,  it  became  evident  that  the  lesion  was 
not  always  due  to  nervous  causes,  but  to  a  local  lesion,  cancer, 
ankylosis  of  the  crico-arytenoid  joint,  while  the  nerve  lesion  may 
have  its  situation  anywhere  from  the  terminal  twigs  to  the  cortex 
of  the  brain.  An  early  clinical  account  of  the  trouble  may  be 
foun(i  in  Tiirck's  first  edition^  in  lS(>(i  where  nimierous  more  or  less 
unclassified  cases  are  reported.  1  )ifferentiation  proceeded  rapidly 
until,  twenty  years  later,  we  find  in  Semon's  voluminous  account^ 
a  summary  of  the  work  in  which  he  had  l>een  preeminent,  where 
the  neuroses  of  the  larynx  have  recei\ed  their  most  authoritative 
modern  exposition  and  classification.  In  a  later  publication-'  he 
has  brought  the  matter  up  to  date,  but  the  question  as  to  the 
origin  of  the  recurrent  nerve  fibers  has  even  yet  (1913)  been  by  no 
means  settled  in  spite  of  the  work  of  Grabower^  and  others,  the 
former  declaring  that  it  arises  not  originally  from  the  spinal 
accessory  by  its  commimication  Avith  it  in  the  skull  but  really 
from  the  nucleus  ambiguus  of  the  vagus.  He  showed'^  that  the 
results  of  paralysis  of  the  larynx,  attained  by  Bernard  and  his 
numerous  imitators,  on  tearing  out  of  their  origin  the  roots  of  the 
accessory,  were  due  to  wounding  of  the  neighl)oring  vagus  centre. 
Cutting  of  the  accessory  roots  produced  no  ])aralysis,  but  when 
the  lower  Aagus  roots  were  severed,  laryngeal  immobility  inter- 
vened; cutting  off  the  upper  Aagus  roots  caused  no  loss  of  motilitj'. 
Further  experiments  of  a  different  kind  by  (yrossmann  and  later 
by  Onodi  led  to  the  same  result. 

Krause,  Semon,  and  Ilorsley  (1.  c.)  had  declared  as  the  result 
of  experimentation  that  the  cortical  center  of  the  brain  is  a  bilateral 
one,  so  that  a  unilateral  cortical  lesion  can  ne\'er  cause  aphasia, 
but  clinical  observation''  has  not  clearly  supj)ortcd  this  view  as 
to  man.  The  experimental  cA'idence  as  obtained  from  animals 
is  so  decisively  and  so  universally  accepted  as  against  this  view 
and  the  clinical  cAidcnce  in  man  is  ojjcn  to  such  serious  criticism, 
it  seems  very  probable  the  fact  has  been  definitely  established  that 
a  unilateral  cortical  lesion  cannot  cause  in  man  either  a  ])ilateral 
or  unilateral  laryngeal  paralysis.  Less  satisfactory  is  the  evidence 
of  a   bilateral   rcj)res(>ntation  of  laryngeal   mo\-em(Mit  in  the  floor 

'  Turck:  Klinik  (1(m-  Krankheiten  des  Kehlkopfcs  vmd  der  Luftrohre,  Wien, 
18G0. 

^  Semon:  Heymann's  Handbuch  tier  Laryngologic  und  Rhinologie,  Wien, 
1898,  Ister  Band,  Isto  Halftr,  ]).  587. 

'Semon:  A  sj-stoni  of  Medicine,  by  manv  writers;  edited  bv  Allbutt  and 
Holiest  on,  Vol.  IV,  Part   II,  London,  I'iKlS,  p"  2.")'.). 

■*  Grabower:  Archiv  fur  Larvngologi(>  uikI  I{hiiiolofz;ie,  1S95,  II,  j).  143. 

'  Grabower:  Centralblatt  fiir  Physiolofric,  1890,  III,  p.  505. 

*  Garel  and  Dor:  .\miales  des  maladies  de  j'oreillf-,  du  larvnx,  etc.,  1890, 
XVI,  pp.  209,  310. 


THE  CENTRAL  INNERVATION  OF  THE  LARYNX         325 

of  the  fourth  ventricle  in  man.  The  cHnical  evidence,  furnished 
by  numerous  cases  of  the  association  of  paralysis  of  nerves,  having 
their  origin  in  this  locality,  is  so  strong  that  it  seriously  militates 
against  the  experimental  evidence  from  which  we  would  infer 
that  here  also  a  unilateral  lesion  cannot  produce  a  laryngeal 
paralysis.  This  also  throws  a  shadow  on  the  conclusions  accepted 
for  the  cortical  problem,  and  it  must  be  allowed  that  to  some 
extent  the  whole  cjuestion  is  still  in  court. 

The  Rosenbach-Semon  law  as  to  the  imiversality  of  the  occurrence 
of  posticus  paralysis  first,  when  the  domain  of  the  recurrent  laryn- 
geal is  involved  by  a  lesion  in  pons,  nerve  or  nerve  periphery,  has  been 
invalidated  by  the  report  of  one  case  as  acknowledged  by  Semon. 
As  a  matter  of  fact  these  authors  had  properly  pointed  out  there 
was  no  "law"  about  it.  It  was  simply  an  obser\ation  that  all 
cases  for  many  years  had  conformed  to  the  statement  that  the 
posticus  is  the  muscle  affected  when  one  laryngeal  muscle  only 
is  paralyzed,  but  no  claim  was  made  that  more  careful  and 
critical  future  analysis  of  clinical  and  pathological  phenomena 
would  continue  to  support  the  universality  of  its  application.  As 
yet  such  critical  analysis  has  not,  with  one  exception,  clearly 
invalidated  it.  The  case  reported  by  Saundby  and  Hewetson^ 
has  been  accepted  by  Semon-  as  free  from  the  criticism  of  mistaken 
observation  and  fully  justifies  his  cautious  reserve  in  refusing  to 
claim  his  rule  to  be  a  law. 

With  the  advent  of  the  toxic  explanation  of  the  peripheral 
paralyses  of  diphtheria,  the  pareses  of  the  pharynx  and  larynx 
often  following  them,  have  fallen  into  line  with  those  ascribed  to 
the  poisons  of  lead,  arsenic,  atropine,  and  even  of  influenza^  and 
gonorrhoea."*  It  is  questionable  whether  these  will  all,  in  the 
future,  continue  to  stand  as  possible  causes  of  peripheral  laryngeal 
paralyses.  Like  some  of  the  cases  ascribed  to  the  toxins  of  rheu- 
matism, it  is  safe  to  predict  that  it  will  be  found  that  some  of  the 
so-called  paralyses  ascribed  to  toxic  origins  are  due  to  something 
else  or  indeed  that  they  are  not  paralyses  at  all  but  ankyloses  of 
the  crico-arytenoid  joint. 

In  the  text-books  which  have  appeared  in  large  numbers,  separate 
consideration  is  given  to  paralyses  of  other  sets  of  muscles  than 
the  postici,  in  accordance  with  the  laws  of  differentiation  as 
involved  by  the  advance  of  knowledge.  There  has  been  a  tendency 
to  include  immobilities  of  the  larynx  which  properly  have  nothing 
to  do  with  the  innervation  in  these  categories  such  as  ankylosis, 
myopathic  immobility,  etc.  The  observations  of  the  laryngeal 
crises  of  tabes,  of  syringomyelia,  of  hypera^sthesia  and  ana?sthesia, 

1  Saundby  and  llowotson:  British  Medical  Journal,  1904,  I,  p.  589. 

^  Semon:  1.  c. 

'  Heymann:  .Archiv  fiir  Laryngologio,  189G  (Fraenkel's  Festschrift),  V,  p.  256. 

*  Lazarus:  Ibid.,  p.  '2'.V2. 


326  LARYNGEAL  PARALYSIS 

of  nervous  coiifi:h  or  chorea  of  the  larynx,  of  hysterical  spasms  and 
paralysis,  of  laryngeal  vertiiio,  have  all  found  their  place  in  the 
text-books  of  larynj^ology,  but  they  belong  more  properly  in  cate- 
gories appertaining  to  the  general  history  of  modern  medicine 
than  to  those  of  a  specialty.  To  this  perhaps  may  be  excepted 
the  curious  cases  of  ictus  laryngis  narrated  by  Schadewaldt^  and 
others,  this  disease  having  been  first  noted  by  Charcot-  in  1876. 

A  few  cases  of  double  posticus  ])aralysis  have  been  reported  from 
time  to  time  as  a  condition  which  is  apt  to  cause  sudden  death,  due 
to  closure  of  the  small  remaining  airway  when  acute  inflammation 
supervenes.  A  similar  condition  is  said  to  be  the  case  of  roaring 
in  horses,  and  the  ojjeration  having  been  successfully  done  in  these 
animals,  it  occurred  to  Hope  to  perform  it  in  man,  but  O'Dwyer,' 
having  previously  tried  it  in  1886  without  avail,  urged  his  procedure 
of  intubation  instead.  He  pointed  out  that  the  cause  of  the  failure 
was  that  the  extirpated  bands  are  soon  replaced  by  other  tissue. 
The  operation,  however,  has  not  been  tried  often  enough  for  passing 
judgment  upon  it. 

In  1897  Grossmann  attempted  to  in\alidate  the  interpretation  of 
the  median  position  of  the  cord  which  attributed  it  to  an  involve- 
ment of  the  postici  muscles  or  their  nerve  supply.  This  criticism  was 
strongly  combated  by  Semon  and  the  discussion  of  the  points  involved 
as  viewed  by  (irossmann  led  to  no  serious  impeachment  of  the  com- 
monly acce])ted  opinion  of  Semon  and  others.^  In  the  course  of  these 
discussions  the  assertion  had  been  repeatedly  made  that  the  cadaveric 
position  of  the  cords  is  rather  a  misnomer  as  applied  to  the  position 
occupied  by  them  in  total  laryngeal  paralysis.  The  measurements 
were  so  difficult  and  so  varying  in  their  results,  in  anything  except 
the  phonatory  position  and  that  of  extreme  abduction  of  the  vocal 
cords,  that  much  dill'erence  of  opinion,  especially  in  animal 
experimentation,  arose  from  this  cause. 

In  connection  with  })osticus  paral^'sis,  it  may  be  of  interest  to 
add  that  a  similar  greater  vulnerability  has  been  claimed  for  the 
extensors  of  the  lower  limb  and  for  the  eyelids.''' 

Doubt  still  remains  even  after  the  lapse  of  ten  years  in  this 
matter  of  the  innervation  of  the  human  larynx.  The  later  work 
of  Katzenstein*^  mav  be  referred  to  as  embod^•ing  some  of  the 

^  Schadewaldt :  Archiv  flir  Laiyngologie,  1896  (Fraenkel's  Festschrift),  V, 
p.  246. 

2  Charcot:  Gazette  mddicale  de  Paris,  1876,  S6r.  4,  V,  pp.  588,  602. 

3  O'Dwyer:  New  York  MtMlical  Journal,  Dwoinber  28,  189.5,  LXII,  p.  833. 

*  Grossmann:  Fraenkel's  Archiv  flir  Laryngologie,  1897,  VI,  p.  282.  Semon: 
Ibid.,  1897,  VI,  p.  492.  Rosonhach:  Ibid.,  1897,  VI,  p.  588.  Fraenkel:  Ibid., 
1897,  VI,  p.  598.  Grabower:  Ibid.,  1897,  VII,  p.  128.  Burger:  It)id.,  1899, 
IX,  p.  203. 

"  Korner:  Vercin  siidfhnitHcher  L;u'vnfj;()l()g(>ii,  19()S,  in  Semon's  Internal. 
Centralblatt  fvir  LaryngoJogie  und  Illiinologic,  1908,  XXIV,  p.  515. 

*  Katzenstein:  Verhandlungen  der  physiologischcn  Gcsellschaft  zu  Berlin, 
Jahrgang,  1901-1902,  vid.,  Archiv  fiir  Anatomic  und  Physiologic,  Physiol. 
Abth.,  1902,  Supplement,  p.  430. 


LARYNGOTOMY  327 

criticism  of  the  now  commonly  accepted  ^'iews  of  Semon,  while 
the  publications^  of  Moller  and  of  Ivuttner  further  complicate  it. 

Throughout  this  period  of  discussion,  a  set  of  cases  was  repeatedly 
described,  exhibiting  involvement  of  the  posterior  cranial  nerves 
supplying  the  palate  and  pharynx,  the  tongue,  the  larynx,  and 
the  sternocleidomastoid  muscle.  Though  Gleitsmann-  credits 
Avellis^  with  being  the  first  to  emphasize  it,  and  it  is  sometimes 
spoken  of  in  late  years  as  the  Jackson-Avellis  complex  or  syndrome, 
it  was  as  long  ago  as  1864  that  Hughlings  Jackson^  drew  attention 
to  the  subject.  In  Tiirck's  book,^  which  was  published  in  186G,  there 
is  a  full  account  of  such  a  case.  PeP  reported  a  case  in  1887,  and 
Wright^  reported  one  in  1889. 

Dr.  J.  Shelton  Horsley^  has  reported  a  case  in  which  after  a 
gunshot  wound  of  the  recurrent  ner\'e,  followed  by  laryngeal 
paralysis,  the  nerve  was  sutured  with  restoration  of  function  on 
that  side,  but  it  is  not  entirely  clear  that  there  was  in  the  first 
place  an  entire  solution  of  continuity  of  the  nerve  fibers.  The 
case,  however,  deserves  mention  as  it  may  encourage  further 
attempts  of  a  surgical  nature  in  proper  though  necessarily  rare 
cases,  even  of  a  pathological  nature. 


LARYNGEAL  CANCER  AND  ITS  EXTIRPATION. 

I  have  already  traced  with  some  care  the  history  of  laryngeal 
growths  and  the  operations  for  their  removal  up  to  the  time  of  the 
perfection  of  the  technique  of  the  intralaryngeal  operation.  It 
soon  became  apparent  that  the  latter  could  not  be  extended  with 
satisfactory  results  to  malignant  growths,  especially  at  a  time  when 
their  differentiation  at  an  early  stage  was  still  undeveloped.  We 
find,  therefore,  that  at  an  early  period  in  the  development  of 
laryngoscopical  diagnosis,  intralaryngeal  procedures  for  their  re- 
moval did  little  more  than  aggravate  the  local  condition,  and  very 
soon  such  attempts  were,  for  the  time  at  least,  all  but  abandoned. 

Laryngotomy. — We  have  noted  records  of  the  opening  of  the 
wind-pipe  for  a  foreign  body  a  hundred  years  before,  and  although 

1  Moller:  Archiv  fiir  Laryngologie,  etc.,  1901-1902,  XII,  pp.  289,  461. 
Kuttner:  Archiv  flir  Laryngologie,  etc.,  1902,  XIII,  pp.  159,  161. 

^  Gleitsmann:  Transactions  of  the  American  Laryngological  Association, 
1908,  p.  197. 

»  Avellis:  Berliner  Kliuik,  October,  1891,  Vol.  XL. 

■*  Jackson:  London  Hospital  Clinical  Lectures  and  Reports,  1864,  Vol.  I,  p. 
361. 

*  Tiirck:  Klinik  der  Krankheiten  des  Kehlkopfes  und  der  Luftrohre,  Wien, 
1866  (Vid.  Ca,se  185,  p.  446). 

6  Pel:  Berliner  klini.sche  Wochenschrift,  1887,  No.  29,  XXIV,  p,  521. 

^  Wright:  New  York  Medical  Journal,  September  28,  1889,  L,  p.  345. 

sHorsIey:  Trans.  South.  Surg,  and  Gvn.  Assoc,  1909,  XXII,  p.  161;  Ref., 
Medical  Record,  January  22,  1910,  LXXVII,  p.  170. 


32S  LARYNGEAL  CANCER  AND  ITS  EXTIRPATJON 

this  had  been  occasionally  repeated,  it  was  not  until  lSo4  that 
the  operation  was  first  done  by  Brauers'  for  a  laryn<;eal  polyp. 
Ten  years  later,  Ehrmann  (1.  c.)  ajjain  o])erated,  supposinij  that  it 
was  the  first  time  the  operation  had  lieen  })erf()rmed  for  relief  from 
a  polyp.  A  preliminary  tracheotomy  had  been  jxTformed;  aphonia 
resulted,  but  the  operation  was  otherwise  a  success,  the  j^atient 
dying  subsequently  from  typhoid  fever  without  recurrence  of  the 

polyp. 

Boerhaave  is  said  to  have  included  "cancerous"  inflammations 
in  his  category  of  laryngeal  afi'ections,  and  ^Morgagni  reported 
finding  the  condition  postmortem.  Scarcely  less  flefinite  was  the 
classification  of  Trousseau  and  Belloc  to  which  I  have  referred 
(page  197).  In  18G5  II.  B.  Sands  reported^  an  external  operation 
as  having  been  done  in  1863  for  laryngeal  cancer  which  had  been 
diagnosticated  by  laryngoscopy.  The  patient  died  within  a  year. 
Sands  was  at  that  time  able  to  collect  reports  of  eleven  thyrotomies 
and  thirty-nine  intralaryngeal  operations  for  growths  in  the  larynx. 
In  the  follow^ing  year  Cabot^  reported  an  external  operation  for  a 
laryngeal  polyp.  Balassa^  in  1868  reported  three  cases,  one  each 
of  papilloma,  carcinoma,  sarcoma,  operated  on  by  laryngotomy. 
He  demonstrated  that  this  could  be  done  without  necessarily  a 
loss  of  voice. 

Thus  far  o])erations  for  laryngeal  cancer,  external  as  well  as 
internal,  had  been  uniformly  disastrous,  some  of  the  patients 
su^vi^•ing  the  operation,  but  none  being  freed  for  any  length  of 
time  from  recurrence.  It  appears,  from  reference  to  a  French 
thesis,^  that  A.  M.  Koeberle  had  suggested  the  possibility  of  total 
extirpation  of  the  larynx  in  1856.  According  to  Foulis  this  was 
actually  carried  out  successfully  ten  years  later  by  Dr.  Heron 
Watson  for  syphilitic  disease.  These  facts,  however,  only  came 
out  later.  Czerny,''  stimulated  to  experimentation  by  the  report' 
of  a  case  of  laryngeal  tumor  extirpated  externally  by  Schrotter, 
W'ho  expressed  a  wish  that  laryngectomy  were  a  feasible  operation, 
demonstrated  on  dogs  its  practicability  in  1870.  On  the  twenty- 
seventh  of  November,  1873,  Billroth  performed  the  operation  on  a 
man^  with  success.    Heine'-*  and  ^Maas^"  repeated  the  operation  in  the 

1  The  case  is  referred  to  by  Albers  in  Graefe  und  Walther's  Journal  der 
Chirurgie  und  Augen-Hcilkundo,  1834,  XXI,  p.  534. 

2  Sands:  New  York  Med.  Jour.,  May,  18(i5,  I,  p.  110. 

5  Cabot:  Boston  Medical  and  Surgical  Jour.,  1SG6,  LXXIV,  p.  32. 

*  Balassa:  Wicn.  med.  Woch.,  1868,  Nos.  91,  92,  93,  XVII,  pp.  1469,  1485, 
1501. 

'  Hermanticr:  Ref.,  Rev.  de,'<  sc.  nicdicalos,  1877,  IX,  p.  29S. 

*  Czerny:  Versuche  iiber  Kehlkoi)f  Extirpation,  Wiener  nied.  Woch.,  1870, 
27,  28,  XX,  pp.  F,ry7,  591.  _ 

'  Schrotter:  Weitere  Beitriige  zur  huyngoskopischer  Chirurgie:  Med.  Jahrb., 
1869,  XVII,  p.  81. 

*  Reported  by  Gussenbauer,  Archiv  f.  klin.  Chirurgie.,  1874,  XVII,  p.  343. 
»  Heine:  Ibid.,  1876,  XIX,  p.  514.  >»  Maas:    Ibid.,  p.  507. 


THE  EMPEROR  FREDERICK  329 

following  year.  At  this  time  Gussenbauer  constructed  his  artificial 
larynx.  Foulis  reported^  his  first  case  in  1877.  Lange  performed 
the  operation  in  America  in  1879,^  and  by  1881  Foulis  had  collected 
the  reports  of  thirty-two  cases  of  total  and  six  cases  of  partial 
laryngectomy.  He  reported  these  statistics  at  the  International 
Congress  in  that  year.'^  The  operation  met  there  with  sharp  criti- 
cism. Two  years  later  Butlin  wrote  a  very  complete  treatise  on 
laryngeal  cancer/  and  in  the  same  year  Cohen,  in  a  careful  analy- 
sis,^ collected  and  analyzed  the  reports  of  sixty-five  cases  of  the 
disease,  and  at  that  time  arrived  at  the  conclusion  that  extirpation 
of  the  larynx  did  not  prolong  life  in  these  cases. 

After  these,  papers  on  the  subject  became  very  numerous.  In 
the  year  188G  alone,  those  of  Newman,*'  Lublinski,''  Hahn,*^  Bara- 
toux,^  Fraenkel/"  Gerster,"  Lange/^  Park,"  Semon  and  Butlin,"  do 
not  by  any  means  exhaust  the  list. 

Fraenkei  (1.  c.)  in  that  year  reported  the  first  successful  intra- 
laryngeal  extirpation  of  a  malignant  growth  and  became  a  partisan 
of  that  procedure  in  selected  cases.  Semon  and  Butlin  warmly 
advocated  the  preference  of  partial  laryngectomy  over  total 
exsection,  rejecting  the  latter  as  unjustifiable. 

The  Emperor  Frederick. — In  January,  1887,  the  Crown  Prince 
of  Germany,  afterward  the  Emperor  Frederick,  began  to  suffer 
from  the  symptoms  of  laryngeal  cancer.  The  unfortunate  quarrels 
between  his  physicians  are  a  part  of  the  reminiscences  of  many 
comparatively  young  men.  As  yet  the  rancor  cannot  have  all 
died  out.  It  is  therefore  unwise  here  to  more  than  refer  to  an 
incident,  from  which  no  one  emerged  with  credit^^  except  the 
unfortunate  and  illustrious  patient. 

While  in  the  published  accounts  of  the  microscopic  findings^'' 
the  impression  received  by  many  was  that  the  growth  was  of  a 
benign  nature,  the  subsequent  course  was  one  of  malignancy  to 
which  this  very  estimable  prince  succumbed  shortly  after  he 
became  emperor. 

1  Foulis:  The  Lancet,  October  13,  1877,  II,  p.  530. 

-  Lange:  Archives  of  Laryngology,  1880,  I,  p.  36. 

^  Foulis:  Transactions  of  the  Internat.  Med.  Cong.,  1881,  III,  p.  251. 

^  Buthn:  On  Malignant  Disease  of  the  Larynx,  London,  1883. 

6  Trans.  Coll.  of  Phys.  of  Phil.,  1883,  Ser.  3,  VI,  p.  353. 

^  Newman:  (ilasgow  Med.  Journal,  Februarj',  1886,  XXV,  p.  236. 

'  Luhlinski:  Berliner  klinische  Wochenschrift,  1886,  XXIII,  pp.  122;  142,  154. 

8  Hahn:  Ibid.,  1887,  XXIV,  p.  918. 

»  Baratoux:  Progres  Medicale,  1886,  Ser.  2,  III,  pp.  263,  308. 
10  Fraenkei:  Archiv  fiir  klinische  Chirurgie,  1887,  XXXIV,  p.  281. 
"  (Jerster:  Annals  of  Surgery,  1886,  III,  j).  20. 
'2  Lang(>:  Ibid.,  p.  38.  "  Park:  Ibid.,  p.  28. 

'^  Semon  and  Butlin:  Brit.  Med.  Jour.,  1886,  II,  p.  975. 

^^  Mackenzie:    The   Fatal   Ilhu^ss   of   Frederick    the    Noble,    Loudon,    1SS8. 
Die    Krankheit    Kaiser    Friedrich    des    Dritten,    dargestellt    nach    amt  lichen 
Quellen,   18S8. 
"•■  Berliner  klinische  Wochensclinrt ,  1887,  XXIV,  p.  445. 


330  LARYNGEAL  CANCER  AND  ITS  EXTIRPATION 

Malignant  Transformations  of  Benign  Laryngeal  Neoplasms.^ 
The  eyes  of  all  the  civiUzed  world  for  months  searehed  the  daily 
papers  for  the  distorted  and  unreliable  news  of  the  progress  of  the 
fatal  malady.  Patients  suffering  not  from  cancer  of  the  larynx, 
but  from  "cancroi)ho])ia,"  filled  the  waiting-rooms  of  the  laryngol- 
ogist.  Not  only  the  lay  mind  in  morbid  horror  had  its  attention 
fixed  on  the  malady,  but  the  scientific  interest  of  medical  men  was 
absorbed  in  the  study  of  many  of  the  problems  of  the  subject.  The 
relative  merits  of  the  intra-  and  the  extralaryngeal  operation  for 
laryngeal  cancer  were  warmly  discussed  in  the  society  meetings 
and  in  the  medical  journals.  The  question  of  the  pathogenesis  of 
cancer  was  universally  discussed.  Its  evolution  from  benign 
forms  of  growth  was  strongly  urged.  At  the  International  Congress 
in  18S1  Solis  Cohen  said:  "I  am  afraid  that  lar\ngologists 
sometimes  convert  innocent  papillomata  into  epithelioma  by 
protracted  manipulation  continued  too  long."  Lennox  Browne 
entertained  the  same  opinion.  Semon  warmly  denied  such  a 
result.  He  immediately  recognized  the  fact  that  if  this  belief 
were  generally  entertained,  and  it  had  been  suggested  by  several 
others,  a  death-blow  had  been  dealt  to  all  intralaryngeal  surgery. 
He  therefore,  by  the  patient  collection  of  an  enormous  number  of 
reports^  from  clinical  observers  all  over  the  world,  thoroughly 
negatived  the  idea  and  thus  rendered  a  great  service  to  Laryngology. 

Pachydermia  Laryngis. — Of  scarcely  less  importance  was  the 
information  as  to  the  histology  of  epithelial  growths  brought  out 
in  the  discussion  aroused  by  this  melancholy  case.  Mrchow  before 
the  Berlin  jMedical  Society  in  1860  first  showed  a  case  which  he 
called  pachydermia  laryngis.  In  1887^  he  reported  on  the  pieces 
first  remo^•ed  from  the  larynx  of  the  German  prince  that  they 
presented  no  e\idence  of  malignancy.  Later  he  wrote''  on  pachy- 
dermia laryngis,  in  which  he  described  the  condition  as  a  simple 
hyperplasia  of  the  epithelium  over  the  \'ocal  processes.  He  laid 
down  the  dictum  that  there  is  a  sharp  line  of  demarcation  between 
the  benign  epithelial  hyperplasia  and  the  stroma,  and  anything  of 
an  epithelial  nature  below  this  line  and  unconnected  with  it  is  at 
least  of  a  suspicious  nature.^ 

In  addition  to  the  one  which  Semon's  collective  investigation 
settled,  the  questions  brought  into  prominence  by  this  case  were: 

L  The  unreliability  of  a  negative  microscopic  diagnosis  in  a 
case  of  suspected  cancer. 

1  Semon:  Intornat.  Centralblatt  fiir  Laryngologie,  1888,  V,  No.  3.  • 

2  Berlin,  klin.  \\och.,  1887,  No.  25,  XXIV,  p.  445;  1887,  No.  28,  XXIV,  p. 
519. 

3  Virchow:   licilincr  klin.  Woch.,  1887,  No.  32,  XXIV,  p.  .585. 

"  See  Bcrl.  klin.  Woch.,  1887,  No.  47,  XXIV,  p.  876.  Virchow  insisted  that  he 
had  only  reported  on  the  character  of  the  pieces  submitted  to  him  for  diagnosis, 
when  he  reported  the  first  i)ieces  removed  from  the  Prince's  larynx  to  present 
no  evidence  of  malignancy. 


LARYNGECTOMY  331 

2.  The  preference  in  the  great  majority  of  the  cases  of  an  exter- 
nal over  an  internal  laryngeal  operation. 

3.  The  question  quickly  answered  was,  the  necessity  in  all  cases 
of  an  early  diagnosis  and  a  prompt  operation  in  incipient  cases. 

Laryngectomy.— Extirpation  of  the  larynx  rapidly  became  more 
common,  and  by  1890  Kraus^  was  able  to  cite  219  cases  of  extirpa- 
tion of  the  larynx,  160  of  which  were  total  exsection  and  142  of 
these  were  for  cancer, 

J.  Solis  Cohen,  notwithstanding  his  former  condemnation  of  the 
operation,  at  first  suggested  the  removal  of  the  soft  parts  within 
the  larynx,  leaving  the  cartilaginous  frame-work,  but  subsequently 
reported^  a  case  in  which  the  whole  larynx  and  two  rings  of  the  trachea 
were  removed,  and  the  stump  of  the  latter  stitched  to  the  episternal 
notch.  The  man  survived  and,  though  there  was  no  communication 
between  the  pharynx  and  the  larynx,  he  was  able  to  articulate  with 
distinctness  by  means  of  pharyngeal  speech.  The  other  alternative 
in  these  cases  has  been  the  insertion  of  a  Gussenbauer  prothesis.^ 
Of  late  years  total  extirpation  of  the  larynx  for  malignant  disease 
has  found  favor  in  Germany  and  America,  while  a  more  or  less 
incomplete  laryngectomy  has  been  the  fa\orite  operation  of  Semon 
and  Butlin  and  the  English  operators.  At  least  Semon  has  of 
late  (1908),  owing  to  the  advance  in  the  technique  of  the  operation 
of  total  laryngectomy,  admitted  that  in  certain  cases,  where  there 
is  no  other  alternative  except  allowing  the  case  to  go  to  a  final 
issue,  laryngectomy  is  admissible,  provided  the  whole  situation 
is  laid  before  the  patient  and  his  consent  is  obtained.^  This  ques- 
tion led  to  a  great  deal  of  very  animated  discussion  in  which  John 
N.  Mackenzie  in  this  country  expressed  rather  extreme  yiews-^ 
while  Semon*^  actively  championed  a  more  conservative  opinion. 
A  fuller  expression  of  this  view  Semon  gave"  in  1904.  Gluck"^  in 
Germany,  Chevalier  Jackson"  and  Brewer^o  in  America  with  great 
boldness  have  attacked  the  problem  of  extirpation  of  the  larynx, 
but  while  their  results  have  been  brilliant  so  far  as  the  operation 
and  its  immediate  sequelfe  are  concerned,  there  can  be  no  doubt 
the  general  consensus  of  opinion  of  laryngologists  is  that,  so 
far  as  the  patient  is  concerned,  between  allowing  the  disease  to 

1  Kraus:  Allg.  Wien.  mcd.  Ztg.,  1890,  Xo.  15,  XXXV,  p.  169. 

2  Cohen:  Xcw  York  Med.  Jour.,  November  12,  1892,  LVI,  p.  533;  Jour,  of 
Laryngology,  Julj^  1892,  VI,  p.  285. 

3  J.  Wolf:  Deutsche  ined.  Woch.,  1892,  Xos.  3  and  33,  XVIII,  pp.  56,  /o4. 
Berl.  khn.  Woch.,  1892,  No.  21,  XXIX,  p.  501. 

*  System  of  Medicine:  Albutt  and  RoUeston,  Vol.  IV,  Part  II,  1908. 

'^  Mackenzie:  Transactions  of  the  American  Laryngological  Association,  1900, 

^'fi^Semon:  Tlie  Lancet,  August  11,  1900,  II,  p.  .393. 

^  Semon:  Lancet,  November  5,  1904,  II,  p.  1263. 

'Gliick:  Congres  internat.  de   m6d.,    Budapest,  1909,  Compte  rendu,    sec. 
15,  Larvng.,  p.  349. 

3  CheValier  Jackson:  Laryngoscope,  August,  1904,  XIV,  p.  590. 

">  Brewer:  Annals  of  Surgery,  November,  1909,  L,  p.  820. 


382  LARYNGEAL  CANCER  AND  ITS  EXTIRPATION 

take  its  course  and  the  fate  of  draj^ging  out  a  few  miserable  years 
of  life  without  a  larynx  there  is  littler  to  choose  and  the  decision 
must  rest  with  the  patient.  Ilis  medical  adviser  should  be  guided 
solely  bj'  the  patient's  attitude  and  by  his  temperament.  The 
chief  hope  in  malignant  disease  of  the  larynx  centres  about  the 
cases  in  which  earlv  diagnosis  is  made.  On  the  other  hand  Gliick^ 
and  others  have  not  hesitated  to  remove  the  larynx  and  with  it 
the  a'so})hageal  or  pharyngeal  wall.  Even  the  tongue  and  hyoid 
bone  ha\ e  been  remo\ed  with  the  larynx.  To  these  radical  operators 
the  existence  of  enlarged  extralaryngeal  lymph  nodes  is  not  always 
a  contra-indication.  The  question  was  fully  discussed  at  the 
International  Medical  Congress  in  Budapest  by  Semon,  Gliick, 
Chiari,  Finder,  and  others,  and  the  points  recorded  abo^'e  recei^'ed 
much  attention,  but  no  material  ad\ance  in  or  change  of  views  can 
be  noted  in  the  reports  of  the  discussion.  While  the  operation  of 
total  laryngectomy  at  present  finds  few  advocates  in  Great  Britain, 
while  there  is  a  tendency  in  America  to  restrict  the  number  in 
which  it  is  advised,  a  very  large  number  of  cases  are  being  reported 
from  the  continent  of  Europe,  and  if  we  are  to  judge  from  these 
the  operation  has  grown  in  favor,  largely  under  the  influence  of 
the  advocacy  of  Gliick.  He  has  probably  done  many  more  of 
these  appalling  operations  than  any  other  one  operator.  His 
statistics  have  never  been  published  in  anything  like  complete 
form,  so  far  as  I  know.  Sendziak,  in  1907,  collected-  the  records 
of  982  cases,  in  which  total  resection  of  the  larynx  was  done  404 
times. 

Owing  to  encouragement  derived  from  the  results  of  operative 
procedures  in  selected  cases  in  which  thyrotomy  and  partial  remo\al 
of  the  larynx  was  done,  more  attention  was  devoted  to  the  early 
diagnosis  of  intrinsic  cancer  of  the  larynx.  It  was  noted  that 
situated  within  the  cartilaginous  box  of  the  larynx,  metastasis 
occurs  late.  It  was  realized  that  cancer  at  a  ^'e^y  early  stage  pro- 
duces hoarseness,  which  should  attract  the  notice  not  only  of  the 
patient  but  should,  after  middle  life  in  the  patient,  arouse  the 
suspicion  of  the  medical  attendant.  Fraenkel,  Semon,  and  others 
in  1900  at  the  laryngological  section  of  the  International  INIedical 
Congress,  and  Mackenzie  and  others  in  America'*  inaugurated  the 
consideration  of  the  finer  dift'erential  diagnostic  points.  There  was 
much  expression  of  opinion  in  criticism  of  the  tendency  to  depend 
too  exclusively  on  the  microscopic  findings.     This  of  late  years 

1  Gliick:  Berliner  klinische  Wochenschrift,  1906,  No.  13,  XLIII,  p.  399,  and 
1908,  XLV,  p.  1870.  Intornaf.  larynf^-rhinolofr.  congres,  Vienna.  Congres 
internat.  med.,  Budapest,  1909,  ('()ini)lc  rendu,  lar.  see.,  j).  349. 

2  Ref.,  Semon's  Internaf.  (\>n1ralblatt  ftir  Laryngologie,  1908,  XXIV,  p.  197. 
See  also  Rev.  h6l)d.  de  Laryngologie,  etc.,  1907,  XXVII,  Part  2,  p.  481;  New 
York  Medical  Journal,  November  30,  1907,  LXXXVI,  p.  1042;  Monatsschrift 
fur  Ohrenhcilkunde,  1908,  Heft  4,  XLII,  p.  179. 

'  1.  c. 


LARYNGECTOMY  333 

has  resulted,  I  think,  in  the  latter  finding  its  proper  position  as  an 
adjuvant  to  the  clinical  symptoms^  in  diagnosis. 

Delavan-  spoke  of  a  case  of  advanced  carcinoma  of  the  larynx 
having  been  treated  in  1902  with  .r-rays.  It  seems  to  have  been 
the  first  so  treated.  Some  cases  have  been  reported  since,  but 
the  results  have  been  nil  and  it  is  now  rarely  resorted  to.  An 
attempt  was  also  made  to  use  radium,  Init  these  measures,  whatever 
mav  have  been  their  success  or  failure  in  malignant  disease  in 
other  parts  of  the  body,  found  no  fa\or  with  laryngologists.  The 
same  may  be  said  of  trypsin  injections.  It  is  no  more  than  common 
frankness  demands  to  acknowledge  that  this  attitude  was  due 
less  to  lack  of  credulity  than  to  lack  of  facilities  for  applying  these 
remedies  to  the  larynx.  They  have  been  profusely  used  in  the 
nose  and  nasopharynx  with  no  success  worthy  of  comment. 

Fulguration,  the  induction  of  a  spark  from  intralaryngeal 
electrode  to  a  laryngeal  growth,  is  a  variation  of  a  method  of  electro- 
cauterization  which  has  received  some  attention^  of  late  years. 
It  has  been  applied  with  reported  success  to  malignant  growths  of 
the  larynx,  and  the  remark  has  been  made  that  its  action  resembles 
that  of  radium.  It  is  too  early  to  positively  pass  judgment  upon 
the  place  it  is  likely  to  take  in  the  therapy  of  the  nose  and  throat. 

And  now  having  followed  the  story  of  our  art  over  its  period 
of  three  thousand  years  and  more;  from  the  dim  and  misty  past 
of  incantations  and  exorcisms;  from  the  early  days  of  Grecian 
ci\"ilization  when  Hippocrates  made  a  specialty  of  medical  science, 
separating  it  from  the  other  sciences ;  to  the  da}'s  of  the  microscope, 
and  the  spectroscope,  and  the  stethoscope,  and  the  laryngoscope; 
when  the  space  of  one  man's  life  is  insufficient  for  him  to  know 
anything  but  the  rudiments  of  our  art  in  many  branches,  and  he, 
at  the  same  time,  in  a  position  to  advance  in  any  degree  the  bound- 
aries of  even  its  smallest  province;  we  may  pause  with,  I  trust,  a 
just  consideration  and  appreciation  of  the  labor  of  our  predecessors. 
Our  knowledge  has  been  built  up,  we  have  seen,  not  by  the  mush- 
room activity  of  any  one  period,  or  of  any  one  school  of  medicine, 
or  l)y  the  premature  birth  of  an  idea  or  theory,  but  by  the  patient, 
painstaking,  laborious  exertions  of  many  generations  of  earnest 
men,  working,  for  the  most  part,  without  expectation  or  perhaps 
desire,  certainly  without  the  attainment  of  those  rewards  by 
which  not  only  the  layman,  but  alas,  even  the  average  member  of 
our  own  art,  measures  what  he  calls  success.  To  him  who  knows 
the  joy  of  work,  this  phenomenon  needs  no  explanation.  To  the 
rest  of  mankind  no  ex])hinati()n  would  suffice. 

•  Wright:  Now  York  Modical  Journal,  July  17,  li>()i>.  XC,  p.  97. 
2  Delavan:  Transact  ions  American  Larynf>;olc)gi(;aI  Association,  1902,  p.  188. 
^\.  Eicliborn:  Vcrcin  (l(nitscli(>r  Laryufioloficn,  19()S,  p.  3.     Ref.,  Semon's 
Internationales  Centralblatt  fur  Laryngologie,  190'.),  XXV,  p.  86. 


INDEX  OF  PERSOML  MMES. 


A 


Abbas,  Halt,  239 

Abeille,  306 

Abel,  300,  304,  318 

Abraham,  231 

Achillini,  117 

Ackermann,  175 

Acquapendente,    Fabricius    ab,     125, 

130 
Acrel,  173 
Adams,  263 
Aetius,  92 
Albers,  183,  215 
Albrecht,  281,  282 
Albiicasis,  100,  101,  102,  103,  115 
Albutt,  331 
Alcmaeon,  41 
Alcock,  247 
Aldrich,  266 
Alexander,  A.,  255,  256,  275,  277,  303, 

304,  308 
Alexander  the  Great,  26 
Alexander,  Trallianus,  93 
Allen,  Harrison,  222,  262 
Alsen,  288 
Althoff,  258 

Amatus  Lusitanus,  147,  148 
Amman,  Johann  Conrad,  191 
Amondeville,  Hemy  of,  112 
Anaxagoras,  42 
Andral,  196,  197 
Andre,  248,  274 
Andree,  161 
Angelo,  Michael,  124 
Anthony  and  Cleopatra,  98 
Antrcchau,  297 
Antyllus,  75 

Aranzi  or  Arantius,  161,  209 
Archagathus,  63 
Archigines,  143 
Aretaeus,  27,  70 
Aristotle,  61 
Arloing,  314 

Arnold  of  Villanova,  239 
Arnold,  266,  311 
Arrowsmith,  253 
Arslan,  307 
Asch,  263 
Aschcnbrand,  244 
Asclepiades,  46,  65 
AseUi,  136,  137 


Auphan,  267 
Aurelianus,  Coelius,  75 
Ausset,  235 
Avellis,  276,  277,  327 
Avenzoar,  100 
Averrhoes,  105,  106 
Avicenna,  100,  114 
Axenfeld,  292 


B 


Baber,  235 

Babes,  318,  319 

Baer,  315 

Baillie,  Matthew,  186,  195 

Balassa,  328 

Balfour,  247 

Ballonius,  152,  155,  158 

Bandler,  223 

Baratoux,  329 

Bard,  Samuel,  186 

Barbier,  229 

Barkan,  236 

Bartel,  311,  314 

Bartholinus,  Caspar,  133 

Bartholinus,   Thomas,    122,    154,    159, 

164,   169,   176 
Barwell,  315 
Bataille,  193 
Batelli,  266 
Bates,  W.  H.,  266 
Bauhinus,  121,  170 
Baumgarten,  230,  262,  271,  306,  312, 

313,  314,  315 
Baumler,  321 
Baurowicz,  276,  318 
Bausch  and  Henkel,  174 
Bayer,  252,  306 
Bayle,  195,  198 
Beattie,  258 
Beausoleil,  236 
von  Beck,  233 
Beckmann,  235 
von  Behring,  227,  312,  314 
Beitzke,  232,  311,  312,  314 
Belfanti,  307 
Bell,  licnjaiuin,  164,  175 
Bell,  Sir  Charles,  17,  173,  187 
Bellini,  132,  138 

Belloc,  147,   196,   197,  202,  215,  328 
Bender,  317 


336 


INDEX  OF  PERSONAL  NAMES 


Benedetti,  149 

Beniveni,  156 

Berengar  del  Carpi,  117,  130,  168 

Berens,  287 

Bergengriin,  316 

Bergson,  268 

Bernard,  Claude,  188,  189 

Bernhardt,  324 

Bernhcim,  313 

Berlin,  175,  191 

Bert  rand  i,  174 

Beschorner,  314 

Besold.  316 

von  Bcsser,  273,  299 

Bichat,  179,  186,  229 

Bickel,  221 

Bidloo.  177 

Billard,  186 

Billroth,  200,  249,  251,  328 

Biot,  192 

Birrh-Hirschfield,  250 

Bischoff,  189 

Blanchard,  257 

Bliss,  235 

Blitz,  232 

Bluhdorn,  230 

Boerhaave,  130,  167,  169,  171,  328 

Bollinger,  313 

Bonet,  176 

Bonninghaus,  245,  264,  287 

Bontekoe,  175 

Borger,  288 

Borsieri,  161,  186 

Bosworth,  233,  258,  259,  261,  271,  285, 

290,  303,  309 
Botey,  237,  284 
Bouchut,  228 
Bowlbv,  276 

Bowman,  \V.,  200,  242,  243 
Brahe,  Tycho,  149 
Branca,  148 
Brasavola,  130,  156 
Braun,  296,  306 
Brawley,  296 
Bresgen,  243,  315,  317 
Bretonncau,  185,  186,  202,  227 
Brewer,  331 
Brindel,  232,  277,  307 
Broeckaert,  305,  307 
Bronner,  304 
Broussais,  195 
Brown,  Lennox,  330 
Brown,  Robeit,  199 
Brucke,  200,  224 
Briigge,  224,  225 
Briigelinann,  303 
Bruhe,  279 

von  Briinings,  294,  319 
Brunn,  244 
Bruno,  127 
von  Bruns,  216 

Brvan,  J.  H.,  270,  277,  278,  294 
Bulklev,  233 
Burger,  236,  320,  326 


Burkhanll,  264 
Buschke,  229 
Butlin,  329 
Butts,  236 


Caboche,  257,  306 

Cabot,  328 

Cagniard,  de  la  Tour,  192 

Calainida,  254,  277 

Callisen,  174 

Calmette,  311 

Calvin,  124,  127 

Canestro,  280 

Cannani,  130 

Cardanus,  133,  134 

Carneades,  63 

Carpi,  Berengar  del,  117,  118 

Cartaz,  315 

Casassa,  307 

Casselberry,  286 

Casserius,  125,  126,  156 

Cassius,  Felix,  89 

Caterina,  307 

Cato,  63 

Caton,  291 

Cauldwell,  282,  287 

Cauliae,  Guy  di,  101,  113,  149 

Cellini,  118 

Celsus,  43,  66  scq.,  148 

Cerlata,  149 

Cesalpinus,  130 

Charaka,  29,  30,  34 

Charcot,  321,  326 

Charles  V,  119 

Chart ers-Symonds,  285 

Chassaignac,  261,  263 

Chavanne,  253,  257 

Cheesman,  John  C,  214 

Chelius,  249 

Cheval,  30() 

Chevalier,  Jackson,  331 

Chiari,  222,  251,  252,  257,  272,  297, 

313,  317,  332 
Chi.si,  154 
Chok-wa,  303 
Church,  211 
Cicero,  65 
Citelli,  254,  277 
Clark,  J.  P.,  259 
Clark,  Laui-ent,  298 
Claus,  283 
Cloquet,  182,  260 
Coakley,  278,  281,  291 
Cobb,  300 
Cock,  188 

Co(h()nicus,  141,  142 
Coelius  Aurelianus,  75 
Coffin,  259,  290 
Cohen,  J.  Solis,  212,  213,  216,  240,  260, 

321,  329,  330,  331 
Cohnheim,  230 


INDEX  OF  PERSONAL  NAMES 


337 


Golden,  155 

Colombo,  124,  168,  183 

Compaired,  307 

Constantine,  the  African,  101 

Cooper,  Sir  Astley,  188 

Cordes,  221,  245,  251,  258,  303 

Cornet,  314 

Cornil,  231,  249,  317,  318 

Cornil  and  Ranvier,  230 

Couvreur,  231 

Cowl,  319 

Cozzolino,  277,  305 

Craig,  230,  293 

Cruveilhier,  256 

Ctesias,  26 

Cullen,  194 

Cutter,  Ephraim,  211 

Cyril,  98 

C>Tus,  the  Great,  17-26 

Cj-rus  the  Younger,  26 

Czermak,  John,  208,  209,  210,  219 

Czerny,  328 


Daae,  306 

Daly,  259 

Damianos,  236 

Daniel,  175 

Darwin,  17,  178 

Daw,  267 

Deichert,  238 

Dekkers,  159 

Delavan,  262,  333 

de  la  Boe,  Sylvius,  130,  137,  193,  194, 

200 
de  la  Tour  Cagnaird,  192,  205 
de  la  Vedova,  307 
Dembowski,  259 
Demine,  306 
Democritus,  42 
Deniocedes,  26 
Denker,  288 
Desault,  160,  173,  228 
Descartes,  139 
Deschamp,  180,  260 
De  Simon  i,  318 
Des  Noues,  136 
Desormeaux,  319 
Detharding,  160 
De  Vecchi,  314 
di  Cauliac,  Ciuv,  239 
l)'haiivantare,^29 
Dickinson,  155 
DiefTcnbach,  261 
Diemerbroek,  132,  169 
Dieulafoy,  231,  232 
Diogenes,  42 
Dionis,  133,  143,  166 
Dionisio,  235,  306 
Dioxippus,  47,  48 
Disse.  247 
Diitricli,  31S 


Dmochowski,  231,  256,  272,  273 

Dodart,  190,  191 

Dodd,  314 

Dogiel,  243,  247 

Donaldson,  323 

Donogany,  258 

Dor,  324 

Donatus,  Marcellus,  158,  214,  315 

Dorion,  235 

Douglas,  William,  155 

Douglas,  John  H.,  211 

Doutrelepont,  318 

Drake,  Francis,  146 

Drews,  224 

Drevfuss,  258,  293 

Duel,  276 

Dumarquay,  262,  268 

Dupuytren,  187 

Duret,  323 

Dursv,  219 


E 


EcKER,  246 

Eckhardt,  246 

Ehrmann,  215,  328 

V.  Eichborn,  333 

von  Eicken,  319 

Eiselsberg,  318 

Elsberg,  211,  212,  213,  216,  259,  322 

Empedocles,  41,  42 

Emperor  Frederick,  329 

Epstein,  297 

Erasistratus,  48,  63,  81 

Erichsen,  203 

Eschweiler,  274 

Etmiiller,  139,  174 

Eudemus,  63 

Eustachius,  136 

Exner,  247,  323 


Faber,  131 

Fabricius  ab  Acquapendente,  125,  130, 

144,  156,  157,  158 
Fabricius  Hildanus,  144,  145,  148,  149, 

170 
Falconi,  248 
Fallopius,  122,  125,  130,  136,  162,  163, 

169 
Fantham,  258 
Fantoni,  194 
Fauvel,  213,  217,  268 
Fein,  257 
Fernelius,  171 
Ferrein,  191,  192 
Ferreri,  237 
Ferrier,  323 
Ficker,  311 

Finder,  G.,  222,  258,  277,  332 
Fischer,  297 


338 


INDEX  OF  PERSONAL  NAMES 


Fit  tig,  319 

Flatow,  289 

Fleming,  224 

Flcxner,  300 

Fliess,  245,  307 

Fonseca,  159 

Forestus,  142,  143,  144,  165 

Fothergill,  153,  154,  155 

Foulis,  329 

Fourcroy,  185 

Fox,  Kingston,  224,  229 

Foy,  307 

Fracassatus,  Carolus,  133 

Fraenkel,  B.,  226,  229,  230,  297,  298, 

299,  302,  306,  308 
Fraenkel,  E.,  226,  227,  233,  234,  241, 

272,  273,  297,  302,  311,  313,  326,  329 
Fraser,  247 
Frederick  II,  106,  116 
Frederick,  Emperor,  329 
Freeman,  294 
Freer,  264,  265,  288 
French,  T.  R.,  193,  268 
Frerich,  249 
Frese,  305 

Freudenthal,  282,  311 
Friedliinder,  270 
Friedman,  234 
Friedreicli,  297 
Fricdrich,  184,  185,  288 
Frisch,  304,  317 


G 


Galen,  82,  148,  168 

Galileo,  128,  139 

Ganghofner,  220,  317 

Gappisch,  298 

Garcia,  Manuel,  206,  207 

Garel,  324 

Garengcot,  160,  239 

Garrigou-Dcsarenes,  306 

Garrison,  306 

Gaudier,  315 

Geber,  317 

Genta,  435 

Gerber,  222,  275,  288,  293,  302,  318 

Gerhardt,  210,  309,  321 

Gerlach,  200 

Gerster,  329 

Gibbs,  210 

Gidionsen,  316 

Giraldes,  256 

Glandorp,  164 

Glas,  245,  255 

Glasmacher,  275 

Gleitsmann,  313,  327 

Glisson,  133,  137 

Gliick,  315,  331,  332 

Goldsmith,  236 

Godskesen,  316 

Goerke,  225,  237 

Goethe,  78,  178,  189,  276 


Goef  jes,  274 

Goldstein,  Max  A.,  VI 

Goldzieher,  319 

Gooch,  173 

Goodale,  222,  224,  225 

Gordon,  111 

Goris,  289,  291,  298,  315 

Gortcr,  167 

Goruc,  232 

Gottstein,  G.,  232,  303,  304,  306 

Gould,  223 

Grabower,  324,  326 

Gradle,  235 

Gradenigo,  307 

Green,  Horace,  201,  202,  203,  211,  212 

Gregory  the  Great,  104,  106 

Grew,  199 

Groedel,  281 

Grosheintz,  234,  241 

Gross,  250,  261 

Grossman,  324,  326 

Griintzncr,  193 

Grimwald,  271,  274,  277,  278,  280,  290, 

291,  304,  315,  316 
Grysez,  311 
Guerin,  311 
Guggenheim,  258 
Guido-Guidi,  156 
Guillemain,  271 
Guisez,  276 
Giintzer,  256,  319 
Gussenbauer,  285,  328,  329 
Guy  di  Cauliac,  101,  113,  239 
Guye,  234 
Guj^ot,  307 


H 


Habermann,  304 

Habicot,  158 

Hack,  259,  260 

von  Hacker,  319 

Hahn,  329 

Ha  ike,  282 

Hajek,  251,  264,  289,  290,  293,  294,  300, 

305,  316 
Halkin,  238 
Hall,  Marshall,  188 
Hallcr,   137,   139,   169,   170,   191,  214, 

217,  2S6 
Haly-Ahbas,  101,  239 
Hansen,  279 
von  Hanscmann,  313 
Hamm,  259 
ll:mimar,  221 
llammerschlag,  226 
Hamonic,  233 
Hamza,  Ispahan,  150 
Harke,  272 
Harmer,  277 
Ilairis,  266 

Hartmann,  277,  278,  287,  302 
Harvey,  129,  130,  131,  136,  140 


INDEX  OF  PERSONAL  NAMES 


339 


Hasslauer,  256,  299 

Havers,  138 

Haymann,  236 

Hebra,  317 

Hedinger,  313 

Heidenheim,  R.,  244 

Heine,  328 

Heister,  160,  167,  175 

Helary,  258 

Hellot,  297 

Hellman,  253 

Helme,  229 

Helmholz,  193 

V.  Helmont,  134,  140,  149 

Hendelsohn,  224,  225 

Henkel,  174 

Henle,  199,  200,  218 

Henrici,  315 

Hermann,  236,  314 

Hermantier,  328 

Hermondeville,  112 

Herodotus,  49 

Herophilus,  62,  63 

Heryng,  226,  270,  297,  310 

Herzfeld,  245,  281,  283,  288 

Herzog,  299 

Hewetson,  325 

Hewlett,  299,  300 

Heylen,  262 

Heymann,  255,  256,  325 

Hicguet,  225 

Highmore,  Nathaniel,  172 

Hildaniis,  Fabricius,  170 

Hildebrandt,  311 

Hilgemann,  314 

Hill,  224 

Hilton,  188 

Hippocrates,  29,  48,  49,  193 

Hirsch,  289,  291 

Hirschberg,  268 

Hirschmann,  283 

His,  201 

Hodenpyl,  224 

Hodgkin,  197 

Hoffman,  136,  153,  275,  292 

Holme,  Francis,  154 

Holmes,  Gortlon,  V 

Holmes,  307 

Homer,  39 

Hooker,  Robert,  199 

Hooper,  323 

Hope,  326 

HojHnann,  235,  237,  251,  252,  301 

Horace,  25 

van  Horn,  John,  164 

Horsley,  291,  323,  324,  327 

Horst,  Gregory,  146 

Horton,  Thomas,  137 

Howai-d,  298 

Hudibras,  149 

Hue,  233 

Huetcr,  298 

Huguemain,  237 

Hulot,  233 


Hunter,  John,  173 
Hutter,  307 
Huxham,  153 
Hvorka,  19 
Hypatia,  98 
Hyrtl,  242 


Imhofer,  317 
Ingals,  262,  285,  286 
Ingersol,  279 
Ingrassias,  124,  155 
Ispahan,  Hamza,  1.50 


Jaccoud,  229 

Jackson,  Chevalier,  319,  331 

Jackson,  Hughlings,  327 

Jacob,  248 

Jacques,  277,  285 

James,  Prosser,  210 

Jankau,  306 

Jansen,  287,  291 

Jarvis,  263,  265 

Jeanty,  270 

Jeleneffy,  322,  323 

Jelinek,  265 

Jessen,  169 

Joest,  232 

Johnson,  321 

Jouana,  313 

Jourdain,  173 

Jouslain,  306 

Jouty,  306 

Julian,  the  Apostate,  88 

Juncker,  160 

Jurasz,  223,  252 

Juret,  258 

Jussi,  174 


K 


Kafemann,  313 

Kahn,  248 

Kalischer,  252 

Kander,  295 

Kaposi,  317 

Kassel,  Karl,  VI 

Katzenstein,  326 

Keen,  321 

Kethubot,  27 

Keves,  248 

Kiesselbach,  253,  255 

Killian,   C,   220,   241,   264,   265,   270, 

27S,  279,  280,  281,  282,  284,  290,  291, 

294,  296,  319,  320 
Killian,  J.,  222 
Kirschner,  277 
Kirstein,  319 


340 


INDEX  OF  PERSONAL  NAMES 


Klamman,  300 

Klebs,  227 

Klinienko,  314 

Klingel,  277 

Knapp,  276,  292 

Knight,  233,  237,  275,  321 

Koch,  230,  310,  311,  313,  315 

Kodcrik,  G.,  214 

Koeborle,  A.  M.,  328 

Koenigstein,  266 

Koorner,  235 

Kohh'ausc'h,  242 

Koller,  Carl,  265 

KolHker,  200,  218,  246 

Kollofrath,  319 

Korner,  326 

Kornfekl,  318 

Korvacs,  314 

Kossel,  314 

Krakowitzer,  211 

Kramer,  315 

Kraus,  331 

Krause,  252,  282,  286,  303,  322,  323, 

334 
Krauss,  284 
Kretschmann,  288 
Krieg,  264,  314,  316 
Krishaber,  309 
Kriickmann,  231 
Krumwiede,  233,  313 
Kubo,  163,  246,  277 
Klihn,  291 
Kuhnt,  284 
Kiimmel,  258 
Kunert,  275 
Kussmaul,  319 
Kuster,  287 
KiUtner,  248,  281,  293,  294,  316,  327 


Labbe, 232 

Lacoarret,  252 

Laonnec,  185 

Laker,  306 

Lamorier,  173 

Lanfranc,  149 

Lange,  255,  329 

Langenbcck,  261 

Larligau,  232 

Lathrop,  279 

Laucnberg,  316 

Laurentius,  17,  12(),  170,  176 

Lavoisier,  267 

Lavrand,  234,  302,  306,  314 

Lavater,  17 

Lazarus,  325 

Ledrans,  165 

Leeuwenhoek.  130,  296 

Lefferts,  217 

Le  Gallois,  187 

Lenart,  258 

Lermoyez,  229,  231,  277,  299 


Lesin,  298 

Leucippus,  42 

Lcvaditi,  300 

Levi-Sirugue,  Chas.,  232 

Levinger,  316 

Levinstein,  222 

Levret,  164,  214 

Lewin,  215,  216,  320 

Lewis,  273 

Lewy,  316 

Liaras,  276 

Lichlwitz,  235,  237,  270,  272,  282,  286 

Lieutaud,  178,  194,  214 

Lisfranc,  156 

Littr6,  171 

Lockard,  317 

Loeb,  280 

Loeffler,  227 

Loewe,  289,  291 

Loewenberg,  219,  235,  262,  300,  304 

Lohnberg,  316 

Loiseau,  228 

Longet,  188,  189,  323 

Louis,  147,  196,  308,  309 

Lower,  140,  267 

Lublinski,  316,  329 

Luc,  284,  285,  287,  304,  316 

Ludwig,  Christian  Gottlieb,  155 

Ludwig,  D.,  199 

Lunin,  236 

Luschka,  218,  220,  246,  256 

Luzzi,  Mondino  di,  112,  116 


M 


MacBride  and  Turner,  232 

AlacBride,  232,  270,  275 

MaeDonakl,  262 

Machaon,  37 

Mackenzie,  Hunter,  311 

Mackenzie,   John   N.,   240,   245,   259, 

332 
Mackenzie,  Morell,  210,  213,  216,  217, 

251,   252,   255,   263,   304,   310,   321, 

322,  329,  331 
McKernon,  237 
Mader,  282 
Magendie,    185,    186,    187,    188,    191, 

192,  323 
Malpighi,  130,  133,  138,  199 
Manasseh,  257 
Mandl,  320,  321 
Mangetus,  140 
Mann.  1()5 

Marcellus  Donatus,  158 
Marccllus  Empiricus,  90 
Muriel te,  21 
Marinus,  82 
xMarshall,  A.  Milne,  247 
Mart  el,  279 
Martin,  227 
Masini,  235 
Massa,  121,  168 


INDEX  OF  PERSONAL  NAMES 


341 


Massei,  304 

Mathieu,  268 

Mayer,  192 

Mayer,  Emil,  290 

Mayer,  F.  J.  C,  218,  220 

Mayer,  Otto,  318 

Mayow,  140,  267 

Meckel,  175 

van  Meckren,  165 

Meibomius,  Jean  Henry,  172 

Meisser,  241,  302 

Menzel,  264,  283 

Mercatus,  Ludovicus,  154 

Merkel,  193,  247 

Mesua,  100 

Meyer,  E.,  230 

Meyer,  Wilhelm,  218,  219,  220,  221, 

222,  234,  241 
Mibelli,  318 
Michael,  235,  240,  260 
Michael  Angelo,  124 
Michaehs,    156 
Michel,  301 

Middeldorpf,  201,  215,  260 
Mikulicz,  270,  286,  317,  319 
Minchin,  258 
Miotlowski,  298 
Mohammed,  18 
Moldenhauer,    252 
Molinie,  307 
Moller,  257,  308,  327 
Mollinetti,  172 
Mondino  di  Luzzi,  112,  116 
Montagnat,  191 
Montaigne,  128 
Montaz,  271 
Moreau,  159 
Morel  Lavalleo,  233,  265 
Morgagni,    147,    167,    170,    175,    176, 

177,  180,  194,  262,  263,  328 
Morgan,  223 
Morrill,  247 
Mosher,  279 
Moskowitz,  291 
Most,  248 

Mom-e,  252,  276,  285,  290,  304 
Moxon,  217 
Mudge,  John,  267 
Miiller,  Johami,  192,  199,  264 
Munch,  296 
Munk,  320 
Myles,  278,  282,  286 


N 


Naegeli,  232,  312 
Napoleon,  186 
Nafier,  237 
Nemai,  316 
Nemesius,  89 
Nenninger,  311 
Nepven,  315 
Neuber,  319 


Neufeld,  237 
Neumann,  255,  329 
Newcomb,  253 
Nichol,  232 
Nicholas,  133 
Nicholas,  Florentinus,  156 
Noltenius,  275 
Nosske,  238 
Nuck,  136,  137 


O'DwYER,  228,  326 

Oertl,  268 

Ogston,  283 

Okada,  252 

Oken,  189 

O'Kinealy,  258 

Omar,  98,  99 

Onodi,  189,  241,  275,  276,  277,  278,  279, 

280,  282,  286,  287,  291,  292,  293,  322, 

323,  324 
Oppenheimer,  257 
Oppikofer,  248,  274,  275,  304 
Oribasius,  88 
Orth,  230,  238,  314 
Otto,  235 


Paaw,  169,  170 

Pacchioni,  138 

Palfin,  147,  167,  170,  174 

Paltauf,  305,  318 

Paracelsus,  134,  139 

Pare,  Ambrose,  128,  129,  148,  170 

Park,  W.  H.,  229,  230,  233,  299,  300, 

313 
Partsch,  287,  289 
PaulIV,  127,  291,  311 
Poulain,  226 

Paulsen,  224,  243,  244,  304 
Paulus,  Aegineta,  74,  75,  94,  148 
Pecquet,  136 
Pel,  327 
Pelletan,  161 
Pellizzari,  317 
Perez,  305 

Perrault,  Claude,  190 
Petit,  165,  194 
Petrarch,  116 
Pctrus  d'Abano,  156 
Peyser,  281 
Pfeiffer,  314 
Pfliige,  312 
Piorry,  183,  184 
von  Piniuet,  232 
Placentinus,  168 
Plaignaud,  174 
Plate,  314 
Platearius,  109 
Platncr,  KiO 


342 


INDEX  OF  PERSONAL  NAMES 


Plant,  230 

Plinv,  24.  25,  26.  63 

Pliuier,  27!) 

Plutarch.  17.  42,  47.  48 

Podalcirus  and  ^lachaon,  37 

Poll,  24.S 

Poclchon,  222 

Polyak,  251 

Port,  28S 

Portal,  194 

Porter,  1S2 

Posey,  292 

Potiquct,  262,  304 

Pott,  Porcival,  165 

Power,  d'Arcy,  290 

Pravaz,  195 

Praxagoras,  (52 

Price,  P.  C,  210 

Priestley,  267 

Proebsting,  236 

Prosser  James,  210 

Przedborski,  316 

Pythagoras,  36,  40 


QuELMALZ,  177,  262,  263 


R 

Raiunowitsch,  314 

Kaleigh,  .Sir  Walter,  146 

Ranvier,  249 

Rapp,  218 

Redi,  296 

Reifhert,  283 

Reid,  .John,  188 

Reiniann,  300 

Reiningor,  170 

Reitmann,  238 

Rethi,  282,  305 

Retterer,  220,  221 

Rptzius,  248 

R  hazes,  74,  100 

Rheiner,  198,  308,  309 

Richards,  238 

Richeraud,  181 

Ricketts,  255 

Riedl,  257,  314 

Riegcl,  321 

Riehl,  317 

Riolan,  17,  136,  164 

Ritter,  285 

Rivin,  137 

Robertson,  Win.,  265,  277 

Robinson,  Beverly,  251 

Robinson,  liryan,  133 

Roe,  259,  263 

Roemer,  292 

Roger  and  Rolando,  111 

Rokitanskv,  197,  198,  309 

Rolando,  ilO,  111 


Rolleston,  331 

Rosenbach.  257,  322,  326 

Rossi,  Marcelli,  257 

Roth,  305,  309 

Rouge,  289,  290 

Rouvillois.  286 

Ruault,  237 

Rudbeck.  136 

Rufus,  74 

Ruge,  298 

Ruhe,  227 

Rupert,  Benedict,  242 

Ruprecht,  262 

Rush,  Chalmers,  156 

Russell,  Risien,  322,  323 

Van  Ruvsch,  130,  132,  138,  174,   177. 

180 
Ryland,  183 

S 

Sabrazes,  235 

Sachs,  200,  257 

Saenger,  311 

Sahura,  21 

Saignelet,  194 

St.  Hilaire,  166 

Saitta,  254 

Sales-Girons,  268 

Salzmann  and  Honold,  171 

Samuel,  27 

Sanctorius,  139,  159 

Sanderson,  310 

Sands,  328 

Santorini,  138,  175,  217 

Sappey,  200,  248 

Sarpi,  130 

Saundliy,  325 

Sauvages,  301 

Sauve,  194 

Sayce,  24,  26 

Schadewaldt,  326 

Schadle,  290 

Schaeffer,  222,  252,  259,  271,  280,  315 

Schalle,  272 

Schaus,  262,  263 

Schech,  252,  257,  309,  313,  315,  316, 

.321 
Scheier,  255,  280,  283 
Schein,  319 
Scheinmann,  287 
Schierf{>rdecker,  245,  248 
Schiragew,  233 
Schleiden.M.  .1.,  199 
Schmidt.  220.  321 
Schmidt,  .Moritz,  270,  315.  316 
Schmiedicke,  317 
Schmi(>ge!o\v.  270,  291,  292 
Schmorl,  313 
Schneider,    Conrad    Victor.    121,    130, 

134,  138,  170,  217 
Schnitzler,  309 
Schoenemann,  304,  306 
V.  Schroetter,  318,  328 


INDEX  OF  PERSONAL  NAMES 


343 


Schultze,  246 

Schlitz,  235 

Schwabach,  220 

Schwager,  255 

Schwann,  199 

Schwartz,  234 

Schwenn,  276 

Scripture,  Edward  W.,  193 

Sehfeldt,  192 

Seifert,  248,  282,  297,  300,  316 

Seiler,  260,  261 

Sekhet'enanch,  21 

Semeleder,  208,  211 

Semon,  Su-  P>hx,    VI,    223,    233,    294. 

315,   316,  320,   322,  323,   324,   325, 

326,  329,  330,  331,  332 
Sendziak,  229,  332 
Sennert,  159 
Serapin,  259 
Servetus,  124,  127,  130 
Sestier,  198 

Severinus,  Marcus  Aurelius,  154 
Sgambato,  154 
Shambaugh,  275 
Shurlev,  227 

Siebeninann,  234,  297,  298,  305 
Sieur,  248,  278,  279.  286 
Sieur  and  Jacob,  278,  280 
Sillcock,  271 

Skillern,  R.  H.,  286,  291,  295,  307 
Sobernheim,  232,  273,  305,  308 
Solon,  36 
Sommering,  180 
Sondermann,  282 
Sorgo,  315 
SpaUanzani,  296 
Spicer,    287 
Spiess,  281,  282 
SpigeHus,  121,  168,  169,  170 
SpiUman,  233 
Steele,  263 
Stein,  315 

Steno,  136,  137,  177,  180 
Stepinski,  307 
Stewart,  278 
Stheemann,  226 
Stieda,  275 
Stirling,  238 

Stohr,  220,  221,  224,  244 
Stork,  210,  316,  322 
Strangenwakl,  211 
Strassmann,  231 
Straus,  311 
Strazza,  277 
Streit,  318 
Strong,  266,  319 
Striibing,  304 
Suchannek,  229,  230,  247 
Sydenham,  155,  174 
Swain,  221,  266 
Sylvester  II,  105 
Sylvius,  120,  128 
Sylvius,  de  la  Boo,  130,  137,  193,  194, 

200 


Tagliacozzi,  148,  149,  150 

Takamini,  266 

Takeya,  314 

Thales,  36 

Theile,  262 

Theisen,  305 

Themison,  66 

Theophilus,  93 

Theoph'lus,  Bishop  of  Alexandria,  98 

Thevenat,  298 

Thierry,  279 

Thomson,  St.  Clair,  177,  293,  299,  300 

Thost,  237,  300,  308,  314,  316 

Tilley,  278,  284,  285,  291 

Tissier,  302 

Titian,  123,  124 

Todd,  242,  243 

Topfer,  238 

Torhorst,  255 

Tornwaldt,  220,  222,  257,  314 

Tortual,  218 

Tovolgyi,  283,  315 

Trallianus,  Alexander,  93 

Traube,  320 

Trautman,  221,  222,  310 

Treitel,  284,  306 

Trousseau,  147,  196,  197,  202,  215,  228, 

328 
Tulpius,  175 
Tiirck,  Ludwig,  208,  209,  210,  213,  268, 

309,  320,  321,  324,  327 
Turner,  232,  273,  274,  282,  285,  292, 

300 
Tycho  Brahe,  149 
Tyson,  Edward,  214 


UcKE,  297 
UfTenheimer,  314 
Uffenorde,  259,  291,  295,  296 
Underwood,  276 


Vacher,  286 
Vail,  259 
Valentin,  300 
Vallisnieri,  171,  296 
Valsalva,  175,  176 
Valverda,  124 
Vansant,  299 
Vauquelin,  185 
Vansteenberghe,  311 
Varohis,  121 
Veillon,  229 
Veis,  316 
Vfelich,  266 
Verheyen,  170,  176 
Verneuil,  254 


344 


INDEX  OF  PERSOXAL  NAMES 


Vesalius,  119,  scq.,  126,  128,  168 

Veslingius,  168,  169 

Vianeo,  149 

Vicq  D'Azir,  78,  160,  178 

\'ieussens,  169 

\'illanova,  239 

\illard,  811 

Villeinin,  230,  310 

Vincent,  230 

VioUet,  299 

Virchow,  249,  255,  256,  296,  309,  312, 

314,  330 
Voltolini,  21,  209,  211,  219,  240,  260, 

311 
Vorschiitz,  291 
Vulpian,  266 


W 

Waggett,  284 

Wagner,  219 

Waldeyer,  201,  220,  247 

Walsham,  232,  238 

Walter,  300 

Watson,  264 

Watson,  Heron,  328 

Watson,  Spencer,  240,  265 

Watt,  182 

\N'eber,  301 

Weichselbaum,  250,  277,  305,  314 

Weil,  264,  281,  293 

Weinhold,  170,  174 

Weiss,  266 

Welcker,  262 

Wepfer,  134,  160 

Wesener,  314 

West,  291 

Wharton,  133,  136 

Wheatstone,  193 


Wierus,  153 

William  of  Salicet,  156,  161 

Willig,  314 

Willis,  Thomas,  125,  129,  140,  177,  193 

Willis,  Robert,  188 

Wlnckler,  283,  315 

Windsor,  211 

Wingrave,  238,  273 

Wirsung,  136 

\\'ichmann,  156 

Woakes,  251,  271,  277 

Wolf,  J.,  331 

Wolfenden,  229 

Wood,  221 

Wormius,  136 

Worthington,  286 

Wright,  Sir  Almoth,  296 

Wright,  J.,  221,  223,  226,  231,  236,  246, 

252,  254,  258,  275,  279,  294,  298,  299, 

311,  313,  319,  327,  333 
Wrisberg,  176 
Wiirtz,  299 


Yersin,  227 


Zansz,  138 

Zarniko,  257,  264,  304 

Zaufal,  301 

Zerbi,  118,  121,  131 

Ziegler,  250 

Ziem,  222,  292 

von  Ziemssen,  322 

Zuckerkandl,  236,  241,  243,  250,  272, 

275,  278,  280,  291,  303 
Zwingler,  172 


INDEX  OF  SUBJECTS. 


Abdominal  cavity,  formation  of,  42 
Abductors,  paralysis  of,  322 
Abscess  of  brain  in  ethmoiditis,  271 

orbital,  292 
Academy  of  Paris,  129 
Accessory  sinuses,  167,  269,  296 

diagnosis  of  wounds  of,   170, 
171 
optic  nerve,  279 
Acini  of  glands,  133 
Actinomj'cosis  of  tonsils,  297 
Addison  on  syphilis,  150 
Adenoids,  74,  219,  234 
anaemia  from,  235 
condition  of  blood  in,  235 
eneuresis  from,  235 
hsemoglobin  in,  235 
instruments   for   operation   upon, 

235 
leukocj^tosis  in,  235 
operations  on,  233,  234 
anaesthetic  for,  236 
haemorrhages  after,  236 
position  in  236 
sequela^  of,  237 
torticollis  after,  237,- 
recurrence  of,  237 
"Adeno-graphia  curiosa,"  136 
Adenoma,  nasal,  249,   251,   252,   253, 

254 
Adrenalin,  266 

"Adversaria  anatomica,"  176 
Air  to  the  heart,  130 

residual,  267 
Album  Graecum,  140 
Alexandria,  60 

libraries  of,  60 
schools  of,  60 
Ampullosum,  os,  124 
Amulets,  88,  90 

and  charms,  disa])pearance  of,  141 
Anaemia  in  adenoids,  235 
Anaesthesia,  local  in  sinus  operations, 

295,  296 
Anaesthesia     in     tonsil     and     adenoid 

operations,  235,  236 
Anatomy  of  accessory  sinuses,  167,  279 
at  Alexandria,  61 
of  Cicero,  64 
in  (jreek  medicine,  61,  62 


Anatomy  in  Hindu  medicine,  35 

of  the  larynx,  125 

nasal,  241,  242,  243 
in  Galen,  78 
in  Papyrus  Ebers,  23 

neglect  of,  99 

of  the  nose  and  throat,  175 

pathological,  175 

revival  of,  1 16 
Ancylotomus,  95 
Angina,  67 

of  Ludwig,  51,  199 

cedematous,  199 

suffocativa,  154,  155 

ulcusculosa,  155 

of  Vincent,  230 
Angioma,  nasal,  254,  255 
Ankvlosis  of  crico-arytenoid  joint,  324, 

325 
Anosmia,  85 

"Anthropologia  Nova,"  172 
Anthropophonik,  193 
Antitoxin  in  laryngeal  diphtheria,  228, 

229 
"Antroskoptrocar,"  283 
Antrum  of  Highmore.     See  Maxillary 

Sinus. 
Antyllus,  tracheotomy  of,  74 
Aphtha  in  infants,  95 
"Appendix    laryngis    ventriculorum," 

176 
Applications,  intralarjmgeal,  202,  210 
Aprosexia,  234 
Arabians,  the,  96 
Arabian  conquest,  97 

science,  influence  of,  105 
Aranzi.    method    of    illumination    in 
rhinoscopy,  162 

polyp  forceps  of,  161 
Area  of  Kiesselbach,  255 
Artificial  larynx,  329 

of  Gussenbauer,  329,  331 
Arts  and  sciences  in  Italy,  decline  of, 

128 
Association,  American  Larvngological, 

213 
Assyrian  medicine,  24 
Asthma,  156 

and  ethmoiditis,  271 
Atlas  of  nasal  Iiistopathology,  248 
Atomic  theory,  42 
Atrophic  rhinitis.    See  Ozacna. 


340 


IXDEX   OF  SLBJECTS 


Auscultation  of  nose  and  throat,  185 
Autosfopy,  319 
Aveiy,  laryngoscope  of,  206 
Ayurvedas,  the,  29 


B 


BATiixfiTOx,  larvnp,()sco!)e  of,  204 
Hal)\ionian  nKHJicinc,  21 
Bacillus,  Klchs-Locfner,  227,  229 
Bacteria,  coli  in  the  nose,  299 

in  inspired  air,  299 

nasal,  296,  298,  299 

of  tonsils,  226 
Bacterial  origin  of  disease,  297 
Bact(>ri()logv  of  nose,  298,  299 
and  throat,  296 

of  ozaena,  300 

of  sinus  disease,  273 

of  throat,  297,  298,  299 
Barkings,  liysterical,  112 
Batteries,  electric,  260 
Baumes,  laryngoscope  of,  205 
Bell,  Benjamin,  snare  of,  164 

tonsil  snare  of,  175 
Belloc's  sound,  164 
Bidmapana,  34 
Bilateral  lesions  in  lai-\ngeal  paralysis, 

324,  325 
Blastema,  197 

Bleeding  polypi  of  nasal  septum,  254, 
255 

after  tonsil  anel  adenoid  operation, 
236,  237 
Blood,      condition    of,     in      adenoids, 

235 
Bologna,  school  of,  116 
Bone  and  cartilage  in  tonsils,  238 

changes  in  ozama,  302 

cysts  of  sinuses,  accessory,  274 

intermaxillary,  78,  122,  178 
Bones  of  l)(>ad,  porosity  of,  1()8 

turbinated,  124,  Vlb 
Bony   cysts,   formation   of  osteoblasts 

and  osteoclasts  in,  275 
Botium,  115 
Bougies,  intranasal,  260 

nasal,  184 
Brain  abscess  and  sinus  disease,  284, 
285 

absorber  of  air,  49 

as  a  gland,  50 

origin  of  catarrh,  49 

refutation  of,  134 
of  nasal  secretions,  79,  80 

pus  from,  172 
Branchus.  135 
"Briiune,"  160 
Bronchoscopy,  319 
Bronchotoni}',  157 
Bronchus  for  larynx,  90 
Burrs,  nasal,  261 
Bursa  pharyngea,  218,  219 


Cabbage  leaves  for  nasal  polypus,  63 

"Cadaveric  position,"  321 

Cagniard  de  la  Tour,  laryngoscope  of, 

205 
Cancer,  laryngeal,  327  to  333 

microscopic  diagnosis  of,  330 

nasal,  in  Ilipj^ocrates,  58 

radium  in  treatment  of,  333 

B()ntgen  rays  in  treatment  of,  333 
"Cancerous"  inflammations,  328 
Cancrophobia,  330 
Canuhc  for  sinuses,  282 
Carcinoma,  nasal,  258 
Cai'tilages,  cuneiform,  176 

laryngeal,  81 

of  Santorini,  175 

tracheal,  healing  of,  160 
Caseous  rhinitis,  277 
Catarrh,  135 

cured  by  coitus,  50 

error  as  to,  131 

Libj'an  therapj'  of,  49 

nasal,  causing  phthisis,  59 

origin  of,  48,  142 

prescription  for,  109 

Schneider's  book  on,  134 
Cathedrals,  116 

Cavildwell-Luc  operation,  287,  288 
Caustics,  intranasal,  260 

in  uvulotomv,  95 
Cautery,  100 

batteries,  260 

intranasal,  142,  260 

Libyan  custom,  102 

nasal  of  Dionis,  143 

to  temples  and  eyebrows,  102 

of  temples  for  catarrh,  49 

in  throat  in  Hindu  medicine,  34 

to  uvula,  144 
Cell,  the,  199 

Cells,    ciliated    of    the    nasal    mucosa, 
246,  247 

ethmoidal,  124,  290 
Cerebral  disease  and  nasal  sinus  sup- 
))uration,  293 

laryngeal  re])resentation,  323 
Cerebrospinal  fluid,  177 
Cervical  glands,  232 

tuberculosis  of,  230,  231,  232 
Cervical  lymjihatics,  232 
Chaldean  m('dicin(\  24 

tiierapy,    disai)pcarance    of,    140, 
141  ■ 
Chamieprosopia,  302 
Chancre,  extragenital,  233 

of  lip,  233 

of  tonsils,  233 
Children,  sinus  diseases  in,  280 

sinus  operations  in,  290 
Chisels,  nasal,  264 

sei)tal,  264 
Choanal  polypi,  277 


INDEX  OF  SUBJECTS 


347 


Chontlroma,  nasal,  259 

Chorea  of  the  larynx,  326 

Church,  influence  of,  106 

Chyliferous  system,  136 

Cicero  on  anatomy  and  physiology,  64 

Circulation  of  blood,  90 

pulmonary,  124 
Civihzation,  li2S,  129 

Arabian,  96,  seq. 

conflict  of,  59,  60 

East  and  West,  44,  45 

Eastern  Empire,  87 

in  Greece,  36 

pre-Renaissance  period,  104 

Renaissance  of,  99,  104,  105,  106, 
107,  108,  115 
Clinics  of  laryngology,  212 
Cocaine,  265 

nerve  injection,  in  sinus  disease, 
296 
Cocci,  pathogenic,  299,  300 
Coccobacillus  of  Perez,  305 
Commerce,  maritime,  influence  of,  115 
Complications  of  accessory  sinus  dis- 
ease, 292,  293 
Compressed  air  spray,  267 
Concha  veneris,  125 
Conservatism    in    nasal    sinus    opera- 
tions, 293,  294,  295 
Constantinople,  88 

exiles  from,  97 

fall  of,  97 
Contracture  theory  of  laryngeal  par- 
alysis, 322 
Cooperatorium,  117 
Cork,  cells  of,  199 
Corpuscles,  IMalpighian,  200 
Cortical  lesions  in  laryngeal  paralysis, 

324,  325 
Coryza,  49,  50,  66 

in  Hindu  medicine,  32 

in  old  people,  50 

and  stomach  disorders,  50 
Cough,  whooping,  156 
Cowper,  operation  of,  172,  173 
Creosote  in  treatment  of  tuberculous 

laryngitis,  315 
Cribriform  plate  of  ethmoid,  49,  93 
Crico-arytenoid    joint,     ankylosis    of, 

324,  325 
Cries,  hysterical,  112 
Croup,  50,  154,  156,  186,  198 

spasmodic,  188 
Croupous  tonsillitis,  229 
Crusades,  influence  of,  107 
Cuculla,  125 
Curabilitv    of    tuberculous    laryngitis, 

315,  316 
Curette  of  Gottstein,  235 
Cylindroma,  nasal,  259 
Cynanche,  67 

etiology  of,  51 

paracynanche,  144 
Cyrus,  his  eye  doctor,  23 


Cystic  polypi  in  the  maxillary  antrum, 

256 
Cysts,  bony  nasal,  256 

dental,  of  maxillary  sinuses,  274, 

275 
dentigerous,  256 
of  middle  turbinated  bone,  275 
nasal,  255,  256 
Czermak,  publications  .of ,  209 


D 


Darwinism,  78,  178 
Death,   facies  of,  in  Hippocrates  and 
in  Shakespeare,  44 

manner  of,  in  diphtheria,  73 
"De  Catarrhis,"  Schneider,  134 
Decortication  of  the  face,  291 
Dental  cysts  of  maxillary  sinus,  274, 
275 

engine,  260 
"De  Sedibus  et  Causis   Morborum," 

176 
Detergents,  267 
Deviations,  septal,  177,  262,  263,  264 

etiology  of,  262,  263,  264 
Diathesis,  tubercular,  195 
Diet,  65 
Differentiation  of  laryngeal  paralysis, 

321 
Diphtheria,  73,  86,  89,  178,  185,  186, 
227,  229 

antitoxin  in  treatment  of  oztena, 
307 

in  Arctaeus,  27,  70 

among  the  Babylonians,  27 

bacilli  in  health}-  throats,  230 

bacillus  of,  229 

in  Cassius  Felix,  89 

in  Forestus,  153,  154,  155 

in  Hippocrates,  50,  51,  52 

laryngeal,  antitoxin  in,  228,  229 

microbian  origin  of,  227 

pharyngeal,  229 

its  reappearance  in  Europe,   153, 
154,  155 

serum  for,  227 

tracheotomy  in,  161 
Diphtheroid  bacilli  in  the  nose,  300 
Disease,  bacterial  origin  of,  297 
Dissection,  116 

at  Alexandria,  61 

by  Michael  Angelo,  124 
Distemper,  sore  throat,  155 
Dogs,  atrophic  rhinitis  in,  305 

excrement  of,  140 

in  Greek  temples,  40 
Drink  in  larynx,  39,  40,  46,  47,  48,  81 

Aristotle,  62 
Drowning  antl  tracheotomy,  160 
Drugs  in  (Jreek  medicine,  36 

stercoraceous,  24,  70,  72 

disappearance  of,  140,  141 


348 


IXDEX  OF  SUBJECTS 


Dung  of  dogs,  24 

of  kids,  2o 
Dys])n(x>a,  .51,  194 

fox  liver  for,  68 


Ear,  broath  tlirough,  44 

labyrinth  of,  42 

tuberculosis  of,  230 
Eastern  eivilization,  decline  of,  96 
Ecchondroses,  sejjtal,  2(51 
Egypt  opcneci  to  (ireeks,  36 
Egj'ptian  civilization,  26 

medicine,  21 
Elastic  fibers  of  nasal  mucosa,  246 
Electrolysis,    submucous    in    atrophic 
rhinitis,  306 

in  treatment  of  tuberculous  laryn- 
gitis, 315 
Elements,    four,    in    Greek    medicine, 

40 
Embryogeiiy  of  the  sinuses,  278 
Endocarditis  in  tonsillitis,  229 
Endoscope  for  sinuses,  283 
Eneuresis  from  adenoirls,  235 
Engine,  dental,  2()0 
Epiglottis,  48,  117,  123,  186 

functions  of,  93 

muscles  of,  in  animals,  123 
Epistaxis,  58 
Epithelium,  glands  in,  244,  245 

keratosis  of,  in  atrophic  rhinitis. 
305 

of  mucous  membrane,  199 

nasal,  taste  buds  in,  244,  245 

passage  of  tubercle  bacilli  through, 
313,  314 
Era,  pre-larvngoscopic,  178 
Erectile  tissue,  241,  242 

difference    in   the    ox    and    bull, 
246 

function  of,  242 

of  septum,  245 
Ethmoid  bone,  49,  93 
Ethmoidal  cells,  124,  290 

sinus,  external  and  internal  opera- 
tions on,  291 
Ethmoiditis  and  asthma,  271 

and  l)rain  abscess,  271 

and  hay  fever,  271 

and  nasal  polypi,  271 

necrosing,  271 

and  orbital  abscess,  271 
Eustachian  tube,  41 
Evoluticm,  7S 
Evulsion  of  tonsils,  233 
Exodus  of  Israel,  22 
Extragenital  chancre,  233 
Eye  disease  in  relation  to  sinus  disease, 

292 
Eye  doctor  from  l']gypt,  23 


F 


Face,  decorticaticm  of,  291 
Facies  of  death,  44 
Fahnestock,  tonsillotome  of,  201 
Fallopius,  nasal  snare  of,  162,  163 
False  membrane,  86 
FalstalT,  facies  of  death,  44 
Faradism  in  atrojihic  rhinitis,  306 
Fat  and  fatty  acids  in  oza?na  secretions, 

303 
Fat  hen  prescription.  111 
Fat    in    mucosa    of    atrophic    rhinitis, 

302 
P'aust  legend,  25 
Febris  scarlatina,  155 
Fever,  catarrhal,  151  seq. 

scarlet,  155 
Fibroma,  pajjillary,  of  nose,  253 
Florence,     health     officer    of,     as     to 

phthisis,  310 
Fluids,  cerebrospinal,  177 

destination  of,  46,  47,  48 
Foam  cells,  317,  319 
Follicular  tonsilHtis,  229 
Forceps  of  Fabricius,  163 
nasal,  263 

for  nasal  polypi,  161,  164 
septal,  263 
of  Stork,  235 
Foreign  bodies  in  nose  and  throat  in 
Hindu  medicine,  34 
in  throat,  93 

removal  of,  101 
Fractiu'es  of  nasal  bones,  87 
of  nose,  96 

in  Hindu  medicine,  34 
bandages  for,  53,  54 
splints  for,  53,  54 
Friedlander's  bacillus,  304,  318,  319 

in  nost^  12 D9 
Frisch  bacillus,  318,  319 
Frontal  sinus,  271 

operations,  283  to  286 

intranasal,  285,  286 
tr(>pliiiiing  of,  171 
Fulguration  in  laryngeal  tumors,  333 
Functions  of  the  human  pharvnx  and 
larynx,  193 


G 


Galen,  anatomy  of,  77 

revolt  from,  119 

times  of,  76  .set/. 
Galvanocauterization   in  treatment  of 

tuberculous  laryngitis,  315 
Galvanocautery  snare,  201 

in  tonsillar  hypertrophy,  237 
Garcia,  laryngoscope  of,  20(5 
Gargles,  milk  of  sheep,  25 
(!arrotillo,  154 
Ghemara,  27 


INDEX  OF  SUBJECTS 


349 


Glandorp,  snare  of,  164 
Glands,  82,  200 

acini  of,  133 

acinous,  200 

Baumann,  stimulation  of,  244 

cervical,  231,  232 

conglobate,  200 

and  conglomerate,  136,  137 

destruction  of,  in  atrophic  rhinitis, 
303 

epithelial  cells  of,  243,  244 

intra-epithelial,  244,  245 

laryngeal,  118,  176 

lymph,  200^ 

mucous,  137 

evolution  of  knowledge  of,  135 

nasal,  132,  243,  244 

racemose,  136,  200 

sublingual,  137 

submaxillary,  137 

of  throat,  122 
Glioma,  nasal,  259 

Goats,  breathing  through  their  ears,  41 
Goitre,  115 

Gottstein's  curette,  235 
Greek  civilization  in  Rome,  63,  64 
influence  of,  107 

medicine  in  Rome,  63 

writers  of  the  Eastern  Empire,  87, 
seq. 
Green  membrane  lining  sinuses,    169, 

170 
Gussenbauer,  artificial  larynx,  329,  331 


Haas'  criticism,  28,  29,  35 
Haemoglobin,  diminution  in  adenoids, 

235 
Ha?morrhage  after  adenoid  operation, 
236 

fatal  from  polypi  operation  with 
forceps,  164 

after  tonsil  operations^  236 

tonsillar,  236 
Hair  pulling  for  relaxed  palate,  101 
Harpsichord  wire  for  snare,  162,  163 
Hay  fever  and  etlimoiditis,  271 
Head  mirror,  208 
Heat  in  therapy  of  ozsena,  142 

in  treatment  of  acute  sinus  disease, 
294 
Herodotus  and  specialists,  22,  23 
Hiatus  similunaris,  polypi  of,  277 
Hindu  and  Greek  medicine,  35,  58 
Hippocrates,  ancestry  of,  37 

era  of,  45 

facies  of  death,  35 

as  a  specialist,  42 
Hippocratic  treatises,  43 

autlicnticity  of,  45,  47 
Histopatliology  of  the  nose,  atlas  of, 
248 


Hoarseness,  112 

prescription  for,  109 
Homer,  nose  and  throat  in,  37 

reference  to  Egyptian  physicians, 
23 

wounds  of  throat  in,  37 
Hopmann's  papilloma,  253 
Horse  hair  string,  100 
Hospitals  in  Paris,  116 
Humoral  pathology,  84 
Humors  to  head,  134 
Hydrops  of  maxillary  sinus,  256,  275 
Hygiene  in  treatment  of  tuberculous 

laryngitis,  316 
Hypochondria,  133 
Hypertrophies,  papillary  of  nose,  252, 

253,  254 
Hypertrophy,  preliminary  to  atrophic 

rhinitis,  305 
Hypophysis,  291 
Hysteria  of  the  larynx,  326 


Iatro-physical     and     iatro-chemical 

schools,  139 
latros,  86 
Ictus-laryngis,  326 
Ignipuncture,  237 

in  tonsillar  hypertrophy,  236 
Iliad,  37,  38  39 
Illumination,  268 

improvements  in,  268 

for  laryngoscopy,  208 
Incantations,  88,  90 
Index  expurgatorius,  127 
Infection  channels  of  the  sinuses,  274 

in  phthisis,  310 

of  tonsils,  226 
Inflammations,  acute  throat,  50 
Influenza,  confusion  with  j^ertussis,  152 

epidemics  of,  150,  151  seq. 

names  for,  151 

and  sinus  disease,  272 
"Infusorial  animalcules,"  297 
Inhalations,  267 

of  oxygen,  267 
Innervation  of  larynx,  187,  320 
Inquisition,  127 
Inspired  air,  bacteria  in,  299 
Instruments,  early  wood  cuts  of,  102, 

103 
Intelligence  of  men,  42 
Intermaxillary  bone,  78,  122,  178 
Internal  secretion  of  tonsils,  235 
Intralaryngeal  applications,  210 

operation,  first,  214 
Intranasal  bougies,  260 
Intratracheal   injections   in   treatment 

of  tuberculous  larvngitis,  315 
Intubation,  114,  228 

in  Hippocrates,  51,  52 

in  posticus  paralysis,  326 


350 


INDEX  OF  SUBJECTS 


Iodoform  in  tuberculous  laryngitis,  315 
Irrigation  in  diagnosis  of  sinus  disease, 

282 
Italian  science,  108 


Jacksox-Avellis  syndrome,  327 
Jacobson's  organ,  177,  180 
Jansen's  operation,  2S6,  287 
Jaws,  deformities  of,  234 
Journals  of  Laryngology,  212 
Juvenal  on  Chaldean  magic,  24 


Keratosis  of  the  faucial  and  lingual 

tonsil  and  of  the  oropharynx,  298 
Kiesselbach's  area,  255 
Kiotom,  175 
Klebs-Loeffler  bacillus,  227,  229 

and    tonsillar    inflammation, 
229 
Knowledge,  diffusion  of,  128,  129 
Kynanche,  67,  71.  87,  109 
etiology  of,  51 
parakj'nanche,  144 
varieties  of,  86 


Labyrinth  of  ear,  42 
Lactic   acid   bacillus  in   treatment   of 
ozaena,  307 
in  tuberculous  laryngitis,  315 
Lacunar  tonsillitis,  230 
Laryngeal  cancer,  327  to  333 
dyspna'a,   194 
glands,  176 
nerve,  median,  323 
paralysis,  320  to  327 

contracture  theory  of,  322 
toxic,  325 
phthisis,  196,  197 
cancerous,  197 
causes  of,  198 
syphilitic,  197 
tubercular,  197 
polyp,  328 
tubercle,  309 
tuberculosis,  195 
tumors,  214,  215 
ulcers,  catarrhal,  309 
vertigo,  326 
Laryngectomy,  328,  329,  331,  332 

in  treatment  of  tuberculous  laryn- 
gitis, 315 
Laryngitis,  erysipelatous,  51 
mixed  infection  in,  309 
a'dematous,  198 
primary  tubercular,  310 


Larvngitis,  tuberculous,  treatment  of, 

315,  316 
Larj'ngocentesis,  159,  160 
Larvngological  Association,  American, 
213 

clinics,  212 

literature,  211,  212,  213 

societies,  212 

teaching,  212 
Laryngology,  chairs  of,  212 

])r()fess()rships  in,  212 

publications  of,  211,  212,  213 
Laryngoscojje,  the,  203,  208 

of  Av(>ry,  206 

of  Babington,  204 

of  liaumes,  205 

of  Bozzini,  204 

of  Cagniard  de  la  Tour,  205 

of  Garcia,  206 

of  Liston,  205 

of  Selligue,  205 

of  Senn,  205 

of  Warden,  206 
Laryngoscopy,  207,  208 

clinical  use  of,  210 

illumination  for,  208 

spread  of,  210 
Laryngotomy,    65,    72,    75,    160,    161, 
327 

in  the  Talmud,  27 
Larj'nx,  anatomy  of,  125 

apjilicators  for,  202 

artificial,  329 

"Bronchus"  for,  90 

cancer  of,  327  to  333 

cartilages  of,  81,  118,  123,  175 

central  innervation  of,  323 

cerebral  localization  of  movement 
of,  323 

chorea  of,  326 

first  operation  in,  214 

by  aid  of  laryngoscopy^ 
215 

fluid  into,  81 

Greek  word  for,  39 

hysteria  of,  326 

innervation  of,  187,  320 

instrument  into,  202 

instrumentum  vocis,  81 

movements  of,  193,  323 

nitrate  of  silver  to,  202 

{lachvdermia  of,  330 

photograi)hy  of,  193,  268 

tubeiculoma  of,  310 

tul)ei-culosis  of,  193 

tumors,  fil)rous,  198 

malignant,  198 

ventricles  of,  176 
Latent  tuberculosis,  232 
"Law,"  Hosent)ach-Semon,  321,  325 
Leech  in  the  throat,  5!) 
Leptothrix  bacilli  in  the  tonsils,  226 

buccalis,  297 

in  throat,  298 


INDEX  OF  SUBJECTS 


351 


Leukocytes,   emigration   of,    220,   221, 

224 
Leukocytosis  and  adenoids,  235 
Levret,  snares  of,  164 
Leyden,  University  of,  129 
Libraries,  Alexandrian,  destruction  of, 

98 
Libyans,  49 
Ligation  of  extremities  in  haemoptysis, 

63 
Ligature  for  uvula,  144,  145 
Lilium  raedicinae,  111 
Lip,  chancre  of,  233 
Lipoid  and  lipoproteids  in  the  tonsils, 

226 
Liston,  lar\Tigoscope  of,  205 
Literature  of  laryngology,  211,  212,  213 
Loop    of   string   in   removal   of   nasal 

polypi,  57 
Ludwig's  angina,  199,  227 
Lupus,  310 
Lymph  glands,  200 
nodes,  136,  200 
Lymphangeioma,  nasal,  259 
Lymphatics,  136 
cervical,  232 
nasal,    247 
of  sinuses,  274 
Lymphocytes  in  sinus  suppuration,  273 
Lymphoid  hypertrophy,  233 
lingual,  lis 
tissue,  220 

fat  in,  222,  223 
histology  of,  220 
physiology  and  pathology  of, 
225 


M 


Macbeth,  witches'  prescription,  25 
Mackenzie,  tonsillotome  of,  201 
Magi,  26 

therajjy  of,  25 
Malignant  nasal  neoplasms,  258 

tumors  of  sinuses,  276 
Malj)ighian  corpuscles,  200 
Massage,  vibratory  in  oza>na,  306 
Mathieu,  tonsillotome  of,  201 
Maxilla,  inferior,  100 
Maxillary  antrum,  cystic  polypi  of,  256 
sinus,    170 

anatomy  of,  172 

disease,  181 

hydrops  of,  256,  275 

operations  on,  172,  173,  174, 
286 

perforation  of,  282 

serous  cysts  of,  275 

serous  disease  of,  275 

surgery  of,  172 

teeth  in,  276 

trephine  for,  173 

tumors  of,  174 


Meat  on  a  string  in  the  treatment  of 

quinzy,  114 
Median  laryngeal  nerve,  323 

position  of  the  vocal  cords,  321 
Medical  science,  reformation  of,   126, 

127 
Medicine  in  Greece,  origin  of,  35 
pre-Hippocratic,  35 

Hindu,  28,  seq. 

origin  of,  according  to  Celsus,  43 

of  the  Parsees,  26 

with  the  Romans,  63 

of  the  Talmud,  27 
Meningeal  disease  and  sinus  suppura- 
tion, 295 

infection  and  sinus  disease,  284 
Meningococcus  intracellularis,  299 

in  nose,  300 
Menstruation,  vicarious,  58 
Meyer,  Wilhelm,  monument  to,  220 

ring  knife  of,  235 
Micrococcus,  catarrhalis  in  the  nose, 

300 
Microscope,  138 

in  diagnosis  of  laryngeal  cancer,  330 
Middle  Ages,  learning  in,  104 
Middle  turbinated  bone  cysts,  275 
Mischna,  27 

Mixed  infection  in  laryngitis,  309 
Mohammetan  Empire,  97 
Moses  and  Papyrus  Ebers,  23 
Mucocele,  276 
Mucosa,  nasal,  effects  of  water  on,  184 

vascular  supplj'  of,  242 
Mucous  membrane,  epithelium  of,  199 

nasal,  smooth  muscle  cells  of,  245 
taste  buds  in,  244,  245 
Mucus,  bactericidal  properties  of,  299 

from  the  blood  and  lymph,  176 

etymology  of,  40 
Muscle  cells  in  the  nasal  mucosa,  245 
Muscles,  intralaryngeal,  81 
Museum,  99 
Mycosis  pharyngis,  297 

tobacco  smoke  for,  297 
Myxoma,  nasal,  249,  250,  251,  252 


N 


Naegeli,  statistics  of,  232,  312 
Nasal  accessory  sinuses,  269,  296 

adenoma,  249,  251,  252,  253,  254 

angeioma,  254,  255 

bacteria,  300 

bougies,  184 

burrs,  261 

caustics,  260 

cautery,  260 

chondroma,  259 

cylindroma,  259 

cysts,  255,  256 

disease,  neglect  of,  238,  239,  240 
treatment  of,  183,  184 


352 


INDEX  OF  SUBJECTS 


Nasal  embiyology,  247      • 

forceps,  niodifications  of,  164 
Slands,  132,  243,  244 
glioma,  259 
lynipliangcMoiiia,  259 
lyinpliatics,  247 

mucosa,  anatomy  of,  242  to  248 
elastic  fibers  of,  246 
olfactory  cells  of,  246,  247 
sexual  fl('veloi)ment  of,  245 
vascular  mechanism  of,  245 
mucous  membrane,  taste  buds  in, 

244,  245 
myxoma,  249  to  252 
neoplasms,  256 

malignant,  258 
osteoma,  256 
papilloma,  252  to  254 
pharynx,  anatomy  of,  222 
polypi,  142,  165,  ISl 

Hindu  instrument  for,  34 
cvdematous,  249  to  252 
operations  for,  110,  165 
protozoa,  257,  258 
reflex  neuroses,  259 
rhabdomyoma,  259 
saw,  26rto  264 

septum,   bleeiling  polypi  of,   254, 
255 
deviations  of,  177 
spurs  of,  177 
snare,  162,  163,  265 
specula,  239 
surgery,  259 
syphilis,  257 
teratoma,  259 
trephine,  261 
tuberculoma,  257 
tuberculosis,  314 
tumors,  transformation  of,  253 
Xasopharj'nx,  photographs  of,  268 
Necrosing  ethmoid  it  is,  271 
Negative     pressui'c     in     diagnosis     of 

sinus  tlisease,  282 
Neglect  of  nasal  disease,  238,  239,  240 
Neoplasms,  benign,  of  nose,  256 

laryngeal  transformations  of,  330 
nasal  malignant,  258 
Nephritis,  in  tonsillitis,  229 
Nerves,  accessory  sj)iual,  188,  189 
median  laryngeal,  323 
olfactory,  120,  131 
pnemiiogastric,  189 
recurrent  laryngeal,  187,  188,  320 

suture  of,  327 
vagus,  187,  188 
"Nervorum  Descriptio  et  Usus,"  132 
Nervous    system    of    the    nose    and 

throat,  175 
Nestorians,  97 
Neuroses,  reflex,  240 
Nodes,  lymi)h,  200 
Nose  in  ancient  records,  18 
bacteri()lf)gy  of,  298,  299 


Nose  of  Brazilians,  18 

in  different  languages,  19,  20 

etymology  of,  19,  20 

fractures  of,  52,  53,  96 

gross  anatomy  of,  241 

of  Hottentots,  18 

of  Huns,  18 

as  an  index  of  character,  17,  18 
of  sexual  development,  17 

injuries  to,  18,  19 

internal,  112 

of  the  Malays,  18 

mutilation  of  (in  Virgil),  19 

pneumococcus  in,  299 

pus  from,  172 

shape   of,  as   indication    of    char- 
acter, 17 

syphiUs  of,  233 

of  the  Tahitians,  18 

teeth  in,  276 

and  throat,  bacteriology  of,  296 

tuberculosis  of,  230 

worms  in,  171 
Nostrils  and  "Breath  of  Life,"  21,  22 

and  embalming,  22 

of  a  nuile,  25 


O 


Obstruction,  nasal  and  mental  acute- 

ness,  49,  50 
Odyssey,  38 

CEdematous  nasal  polypi,  249  to  252 
CEsophagoscopy,  319 
Ogston-Luc  operation,  284 
Olfaction,  49,  93,  94,  180 
Olfactory  epithelium  of  nasal  mucosa, 
246,  247 
nerves,  93,  94,  120,  121,  131 
Operation,  Cauldwell-Luc,  287,  288 
flrst  intralarvngeal,  215 
Jansen,  286,' 287 
Ogston-Luc,  284 
Rouge,  289 
Operations  for  adenoids,  233,  234 
anesthesia  in,  235,  236 
on  hypophysis,  291 
polyi)i,  nasal,  164,  165 
septum,  nasal,  261 
plastic,  261 

submucous,  262,  263,  264  j^ 
sinus  in  children,  290 

conservatism  in,  293,  294,  295 
frontal,  intranasal,  285,  286 
maxillary,  286  to  290 
sphenoid,  291 
tonsils,  233 

ana'sthesia  in,  235,  236 
tumor,  post-nasal,  103 
Optic   nerve   disease   and   sinus   affec- 
tions, 292 
nerves  and  accessory  sinuses,  279 
Orbital  abscess,  292 


INDEX  OF  SUBJECTS 


353 


Orbital  abscess  and  ethmoiditis,  271 

Organ  of  Jacobson,  177,  180 

Os  ampuUosum,  124,  168 

Osphresiologie,  182 

Ossa  turbinata,  125 

Osteoblasts  in  formation  of  bony  cysts, 

275 
Osteoclasts  in  formation  of  bony  cysts, 

275 
Osteoma,  nasal,  256 
Ovid's  prescription,  26 
Oxygen,  discovery  of,  267 

inhalation  of,  267 
Oztena,  68,  69,  85,  142,  181,  300 

bacteriology  of,  300 

bone  changes  in,  302 

different iat ion  of,  301  to  305 

dog  and  rabbit,  305 

etiology  of,  301  to  305 

following  hypertrophy,  302  to  305 

Friedlander"s  bacillus  in,  304 

Hindu  medicine,  32,  35 

histology  of,  301  to  305 

lactic  acid  bacillus  in  treatment 
of,  307 

scrofulous,  315 

and  sinus  disease,  271,  277,  304 

syphilitic  etiology  of,  302 
origin  of,  303 

in  the  Talmud,  27 

therapy  of,  142 

tracheal,  304 

treatment  of,  306,  307 

by  diphtheria  antitoxin,  307 
by  lactic  acid  bacillus,  307 
by  paraffin  injection,  306,  307 
by  vaccines,  307 

as  a  trophoneurosis,  306 

tubercular  origin  of,  303 

vibratory  massage  in,  306 

Wassermann  reaction  in,  305 


Pachydermia  laryngis,  330 
Palates,  high,  234 

inflammation  of,  and  cure,  100,  101 
Papillary  fibroma  of  the  nose,  253 

hypertrophies    of    the   nose,    252, 
253,  254 
Papilloma,  Hopmann's,  253 

nasal,  252,  253,  254 
Papyrus,  Ebers,  22,  23 
Paracynanche,  52 

Paraffin  in  treatment  of  oza^na,  307 
Paralysis  of  abductors,  322 

laryngeal,  320  to  327 

differentiation  of,  321 

phonatory,  321 

posticus,  320 
double,  326 

respiratory,  321 
Paris,  academy  of,  129 

23 


Percussion  of  the  nose  and  throat,  185 
Perez,  cocco-bacillus  of,  305 
Perforation  of  maxillary  sinus,  282 
Pergamos,    Libraries   and   Schools   of, 

60,  98 
Peritonsillitis,  52 
Persians,  17 

Pertussis,  confusion  with  influenza,  152 
Petum,  146 

Pharyngeal  bursa,  218,  219 
mvcosis,  297 

tonsil,  138,  217,  218,  219,  222 
acute  inflammation  of,  235 
Pharyngitis,  erysipelatous,  51 
Pharyngomycosis  sarcinica,  297 
Pharynx,  Greek  word  for,  38,  39 
phlegmon  of,  227 
tumor  of,  176 
Phlegmon  of  the  pharynx,  227 
Phonatory  paralysis,  321 
Photographs  of  nasopharynx,  268 
Photography  of  larynx,  193,  268 
Phthisis,  infection  in,  310 

laryngeal,  193,  194,  196,  197 
pulmonalis,  195 
Physick,  tonsillotome  of,  201 
Physiognomy  of  the  nose,  17 
Pin  operation  for  nasal  septum,  263 
Plates,  anatomical,  of  Vesalius,  123 
Platyrrhinia,  302 
Pleurisy  in  tonsillitis,  229 
Pliny,  therapy  of,  69 
Plutarch  on  the  senses,  41 
Pneuma,  67,  139 
Pneumatists,  72 
Pneumococcus  in  the  nose,  299 
Pneumogastric  nerve,  189 
Polypi,  85 

choanal,  277 
laryngis,  328 

nasal,  63,  69,  95,  142,  181,  249  to 
252 
classification  of,  181 
and  ethmoiditis,  271 
Fallopius  snare  for,  163 
forceps  for,  161,  163 
in  Hindu  medicine,  35 
in  Hippocrates,  55 
Japanese  snare  for,  163 
knotted  string  for,  95 
operations  for,  161 
pathogenesis  of,  165,  166,  167 
snare  for,  162,  163 
treatment  of,  181 
in  the  sinuses,  277 
Posticus  paralysis,  320 
double,  326 
extirpation  of  vocal  cords  in, 

32() 
intubation  in,  326 
Postmortem  examinations  of  accessory 

sinuses,  271 
Post -rhinoscopy,  211 
Powder  l)l()wei-,  144,  145 


354 


INDEX  OF  SUBJECTS 


Pramarsa,  .34 

Pregnancy    in    tuberculous 

316 
Prelarvngoscopic  era,  178 
Prosthetics,  147,  14S 
Protozoal    graniiloiiuita    in 

257,  25S 
Pscudocroup,  \'A') 
Publications  of  laryngology, 
Pulse,  (i2 

Purulent  rhinitis,  303 
Pus  from  brain,  172 
from  nose,  172 


Ring  knife  of  Meyer,  235 
laryngitis,    Ring  of  \\'aldeyer,  201 

Rontgen  rays  in  treatment  of  laryngeal 
cancer,  333 
rhinoscleroma,  319 
tlie    nose,  tuberculous  laryngitis,  315 

Rontgenology  in  sinus  disease,  280  to 
282 
211  to  213    Rosalia,  155 

Rosenbach-Semon  ''law,"  321,  325 
Rouge  operation,  289 
Rubeola,  155 


Qi'ALiTiEs  of  matter,  11 
Queen's  plant,  146 
Quintilian  on  Hippocrates,  48 
Quinzy,  51,  67 

in  Hindu  medicine,  31 

treatment  of,  114 


Rabbit,  oza'na  in,  305 

Radium    in    treatment    of    laryngeal 

cancer,  333 
Recurrence  of  adenoids,  237 
Recurrent  larvngc^al  nerves,  82,  83,  187, 
188,  320 

suture  of,  327 
Reflex  nasal  neuroses,  240,  259 
Renaissance,  115 

Arabian,  99 

results  of,  141 
Residual  air,  267 
Respiratory  jjaralysis,  321 
Rhabdomyoma,  nasal,  259 
Rheumatism  and  tonsillitis, 
230 


226, 
Sec  Ozffina. 


229, 


Rhinitis,  atroj)hic. 

caseosa,  277 

hypertrophic,  prcliniinarv  to  atro- 
phic, 302 

purulent,  303 
Rhinoliths  in  Hijjpocrates,  58 
Rhinophar3'ngoscoj)y,  209 
Rhinoplasty,  148,  149,  261 

in  Sicily,  148 

in  Hindu  medicine,  32 
Rhinoscleroma,  317 

foci  of,  3 IS 

Rontg(>n  rays  in  treatment  of,  319 

serology  of,  318,  319 

and  sj'philis,  317 

vaccines  in,  319 
Rhinoscopy,  anterior,  162 

illumination  in,  1()2 
Rhinos})oridium  kinealyi,  258 
Rhinostenoma,  183 
Rig  Veda,  29 


S 


Salekxo,  school  of,  109,  116 
Saracens  and  rhinojjlasty,  148 
Sarcoma,  85 

nasal,  258 
Saw,  nasal,  261,  263,  264 
Scarlet  fever,  155 
Schneider,  predecessors  of,  133 
Scorpio,  101 
Scrofulous  ozjena,  315 
Secretions,    nasal,    carried    to    blood- 
vessels, 176 
Selligue,  laryngoscope  of,  205 
Semon's  Centralblatt,  VI,  223,  227 
Senn,  laryngoscope  of,  205 
Senses,  the,  41 
Septal  chisels,  264 

deviations,  177,  262  to  264 
forceps,  263 
operations,  261 
pin,  263 
plastic,  261 

submucous,  262  to  264 
splints,  263 
spurs,  177,  261 
Septum,  nasal,  bleeding  i)o!vpi  of,  254, 
255 
shortening  of  as  cause  of  ozfcna, 
301 
Sequelae  of  adenoid  oi)eration,  237 
Serapion,  the,  98,  99 
Serology  of  rhinoscleroma,  318 
Serous  cysts  of  maxillary  sinus,  275 

disease  of  maxillary  sinus,  275 
Seventeenth  century  theories,  139 
Sexual  development  of  nasal  mucosa, 

245 
Shakespeare,  facies  of  death,  44 
Shalaka,  35 

Sinus  affections  and   ojjtii'   nerve  dis- 
ease, 292 
canula^,  282 

disease,  acute,  treated  by  heat,  294 
l)acteriol()gy  of,  273 
beginnings  of  interest  in,  270 
and  brain  abscess,  284,  285 
comi)lications  of,  292,  293 
dental  origin  of,  273 
diagnosis  by  irrigation,  282 


INDEX  OF  SUBJECTS 


355 


Sinus   disease,    diagnosis  by   negative 
pressure,  282 
by  Rontgenology,  280  to 

282 
by  transillumination,  270 

etiology  of,  273 

and  influenza,  272 

latent,  271,  272 

and  meningeal  infection,  284 

and  oza^na,  271,  304 

in  relation  to  eye  disease,  292 

Rontgenology  in,  280  to  282 

and  vaccine,  296 
endoscope,  283 
ethmoidal,    external   and   internal 

operations  on,  291 
frontal,  169,  170,  271 

operations  on,  283  to  286 

worms  in,  170 
maxillary,  170 

cystic  ])olyi)i  of,  256 

hydrops  of,  256 

operations  on,  173,  174 

surgery  of,  172 

teeth  in,  276 
operations  in  children,  290 

local  anaesthesia  in,  295,  296 
oziena,  277 

perforation,  death  from,  283 
sphenoidal,  118,  168,  169,  170,  291 
suppuration  and  cerebral  disease, 
293 

and  Ivmphocytes,  273 

and  meningeal  disease,  295 
trocars,  282 
tuberculosis,  277 
Sinuses,  accessory  nasal,  269,  296 
anatomv  of,  167,  279 

in  "children,     168,     169,    170, 
280 
channels  of  infection  in,  274 
contents  of,  169,  170,  172 
cysts  of,  274 

diagnosis  of  wounds  of,   170,    171 
diseases  of,  in  children,  280 
embryogeny  of,  278 
empyema  of.  in  children,  280 
function  of,  168,  169,  170 
granulation  tissue  in,  273 
green  membrane  in,  170 
histology  of,  273 
lining  of,  169,  170 
lymphatics  of,  274 
malignant  tumors  of,  276 
polypi  of,  277 

and  postmortem  examination,  271 
and  skiagrai)hy,  280,  282 
stomach  contents  in,  274 
suppuration  of,  270 
worms  in,  171 
wounds  of,  170 
Sinusitis,  59 

Sixteenth  century  j)ractice,  142 
Skiagrai)hy  in  sinus  disease,  280  to  282 


Snare,  galvanocautery,  201 
first  of  wire,  163 

of  Glandorp,  for  nasal  polypi,  164 
Japanese  for  nasal  polypi,  163 
Jarvis,  263 
nasal,  265 

of  Fallopius,  163 
for  tonsils,  175 
Snuffs  in  Hindu  medicine,  32 
Societies  of  laryngology,  212 
I  Society,  Royal,  of  London,  129 
1  Sorcery,  25 

!  Sore  throat,  distemper,  155 
i  Special  treatises  on  nose  and   thro:it, 

180  to  183 
Specialists  in  Egypt,  22,  23 

Montaigne's  remark,  22 
I  Speculum,  nasal,  101,  239 
I  Sphenoidal  sinus,  168,  291 
I  turbinated  bones,  175 

Splints,  nasal,  53,  263 
goose  quill,  54 
lung  of  sheep,  53 
Sponge  in  removal  of  nasal  polypi,  56 
Spray,  compressed  air,  267 
!  Spurs  of  nasal  septum,  176,  261 
'Squinantia,  109.  110 
Squinzy,  1 10 
Staphvlocaustos,  95 
Statistics  of  Naegeli,  312 
Steel  nail,  235 
Stercoraceous  drugs,  90,  101 
Sternutatories  in  Hindu  medicine,  32 
Stomach  contents  in  the  sinuses,  274 
'  Stork's  choanal  forceps,  235 
i  Streptococci  in  throat,  229,  299 
'  Streptothrix  in  the  throat,  297,  298 
Stroboscopy,  26S 
Styloid  process,  63 

and  tonsils,  238 
Submucous  septal  operations,   262  to 

264 
Suffocative  angina,  154 
Sunken  tonsils,  238 
Sunlight   in   treatment  of  tuberculous 

laryngitis,  315 
Superstition,  early  Greek,  40 
Surgery,  intranasal,  174,  259 

of  the  tonsils,  174 
Surgical  operations  in  Egjqot,  24 

in  Zend  Avesta,  24 
Susruta,  29,  30,  34,  58 
facies  of  death,  35 
Suture   of   recurrent   larvngeal   nerve, 

327 
Swallow    })rescrii)ti()n    in    sore   throat, 

67,  68,  90,  101 
Synanche,  65,  67,  71,  87.  90,  109 
S.yndrom(\  .Jackson-Avclli-;.  327 
Sypliilis,  146,  147 
Addison  on,  150 
in  Aretaeus,  71 
as  a  factor  in  oziciia,  302,  303 
in    Hesiod,  55 


356 


INDEX  OF  SUBJECTS 


Syphilis  in   Hindu  nicdicinc,  33 

in  Hippocrates,  o4,  55 

larvnfioal,  1  IS 

nasal,  142,  --'33,  257 

and  rhinosclnonia,  317 

of  throat,  233 

of  tonsil,  233 
Syriac  nlcor,  27,  73 
Syrui)s  and  elixirs,  !)9 
System,  chylifcM'ous,  13() 
Systems  of  medical  publications,  184 


Tattlkk,  The 
Tea  drinking,  146 

and  tobacco  as  medicines,  176 
Teaching  of  laryngology,  212 
Teeth  in  nose,  27(5 
Teratoma,  nasal,  259 
Therapy  of  tonsillary  hypertrophy,  143 
"Thesaurus  Anatomica,"  132 
Throat    affections,    differentiation    of, 
155 

bacteriology  of,  229,  296  to  299 

leptothrix  and  streptothrix  in,  298 

streptococci,  229,  299 

syphilis  of,  233 

words  for,  Cheek,  3S,  39 
in  Hindu  medicine,  35 
Thrombine,  266 
Thrombokinase,  266 
Thyroid,  physiology  of,  136 
Thyrot()my,'l61,  329 

in  treatment  of  tuberculous  laryn- 
gitis, 315 
Tissue,  erectile,  241,  242 
Tobacco  smoke  in  treatnunit  of  mycosis 
l)haryngis,  297 

and  tea  as  medicines,  I7() 

therapy,  145,  146 

for  worms  in  nose,  171 
Tongue,  extirpation  of,  91,  92 
Tonsillar  chancre,  233 

hemorrhage,  236 

hyjx'rtrophy,  galvano-cautery  in, 
■  237 

inflammation    and    Klebs-Loeffler 
bacillus,  229 

syphilis,  233 

tuberculosis,  231,  232,  233 
Tonsillitis,  174 

croupous,  229 

follicular,  229 

lacunar,  230 

bacteriology  of,  230 

membranous,  230 

and  red  hair,  1 7  1 

and  rheumatism,  229,  230 
Tonsillotomes,  201,  233 

of  Fahnestock,  201 

of  Mackenzie,  201 

of  Mat  1  lieu,  201 


Tonsillotomes  of  Physick,  201 
Tonsillotomy,  102,  HI,  144.  201 

in  Hindu  medicine,  31,  32 
Tonsils,  95,  200,  217,  234 
accessor^',  223 
actinomycosis  of,  297 
and  adenoids,  217 
anatomy  of,  221 

and  piiysiology  of,  222 
bacteria  of, "226,  229,  230 
bone  anil  cartilage  in,  238 
carmine  in,  224 

and  coli  communis  bacterium,  229 
comparatiye  anatomy  of,  218,  219 
diseases  of,  174 
embryology  of,  220,  221 
and  endocarditis,  229 
ejiithelial  origin  of,  221 
epithelium  of,  226 
evulsion  of,  52,  233 
extract  of,  used  as  injection,  235 
fat  in,  222 
foramina  of,  mistaken  for   ulcers, 

174 
function  of,  223,  225 
histology  of,  224 
hook  for,  95 
hypertrojjhy  of,  143,  225 

ignii)uncture,  236 

influence  of   jniberty  on,  143, 
144 

and  tuberculosis,  231,  232 
in  immunity,  226 
infection  of,  226 
internal  secretions  of,  235 
k(n-atosis  of,  226,  298 
leptothrix  bacilli  in,  226 
literature  on,  217 
and  nephritis,  229 
mmiber  of,  74 
operations  on,  175,  233,  238 

aiui'stlietics  for,  236 

h(>morrhage  after,  236 
pharyngeal,  138,  217,  218,  219,  222 

cyst  of,  222 
I)hysiology  of,  223,  225 
and  i>leurisy,  229 
as  portals  of  infection,  229 
as  protection  to  the  sj^stem,  225 
and  rheumatism,  226 
scarification  of,  65 
and  sexual  organs,  223 
snare,  175 

and  styloid  process,  238 
sunken,  23S 
su])ernumerary,  223 
surger\'  of,  174 
tuberculosis  of,  230,  312 
Tornwaldt's  disease,  219.  222 
Torticollis    after    adenoid    operation, 

237 
Toxins  in  the  etiology  of  ozaMia,  305 
Tracheal  o/.a'ua,  304 
Tracheoscopy-,  319 


INDEX  OF  SUBJECTS 


'Sb'i 


Tracheotomy,  74,  76,  95,  96,  100,  111, 
156  to  159 

in  diphtheria,  161 

in  drowning,  160 

in  treatment  of  tuberculous  laryn- 
gitis, 315 

tubes,  156 
Transformation  of  laryngeal  neo- 
plasms, 330 

of  nasal  tumors,  253 
Transillumination,  270 
Trephine  for  maxillarv  sinus,  173 

nasal,  261,  264 
Trephining  of  frontal  sinus,  171 
Trocars  for  sinuses,  282 
Troches  for  cough,  82 
Trophoneuroses,  the  origin  of  ozsena, 

306 
Tubercle  bacillus,  233 

bovine,  233 

demonstration  of,  311 

passage  through  epithelium,  313, 
314 
Tubercle  in  larvnx,  309 
"Tubercular  Diathesis,"  195 

laryngitis,  primary,  310 
Tuberculin    in   treatment   of   tubercu- 
lous laryngitis,  315 
Tuberculoma  of  larynx,  310 

of  the  nose,  257 
Tuberculosis,  bovine,  313 

dormant,  312 

of  ear,  230 

in  etiologv  of  ozsena,  303 

forms  of,  "^3 10 

larval  in  oza?na,  306 

larvngeal,  193,  195 

latent,  232 

nasal,  230,  314 

primary,  313 

routes  of  infection,  311 

of  sinuses,  277 

and  syphilis  of  larvnx,  194 

of  tonsils,  230  to  233 

universal  infection  with,  311 

of  upper  air  passages,  308  to  316 
Tuberculous    infection,     methods    of, 
311,  .^eq. 

laryngitis,       curabilitv     of,     315, 
316 
in  pregnancy,  316 
treatment  of,  315 
Tubes,  tracheotomv,  156 
Tumors,  laryngeal,' 111,  214,  215,  216 

fulguration  in,  333 

of  maxillar,v  sinus,  174 

of  pharynx,  176 

post-nasal,  103 

of  throat.  Papyrus  Ebers,  23 
Turbinata  ossa,  125 
Turbinated  bones,  124,  125 

sphenoidal,  175 
TUrck  and  C'z(>rmak  in  I'rance,  209 

publications  of,  209 


"Ulcers  in  Tube  of  Lungs,"  193 
Universities,   116 
Uvula,  70,  SO,  lis,  144 

among  the  Greeks,  62 
Uvulotome,  145,  175 
Uvulotomy,  52,  95,  HI 

among  the  Greeks,  62 

in  Hindvi,  31 


Vaccines  in  rhinoscleroma,  319 
in  sinus  disease,  296 
in  treatment  of  oza;na,  307 

Vagus  nerve,  187,  188.  189 

Valves  of  the  veins,  130 

Vaporization  in  Hindu  medicine,  32 

Vapors,  134 

to  head,  134 

Vascular  theory  of  nasal  glands,  132 

Veins,  valves  of,  130 

Ventricles  of  the  larynx,  176 

Vertigo,  laryngeal,  326 

Vesalius,  anatomical  plates  of,  123 

Vincent's  angina,  230 

"Vital  heat,"  139 

Vivisection  at  Alexandria,  61 

Vocal  cords,  extirpation  of,  in  posticus 
paralysis,  326 

Voice,  187,  190,  193,  223 
from  brain,  83 
Codronicus  book  on,  142 
exercise  of,  95 
formation  of,  42,  80,  81 
and  hearing,  organs  of,  125 
from  the  heart,  81 
modification  of,  by  laryngeal  ven- 
tricles, 176 
organ  of,  in  Aristotle,  62 

Vomicte  in  the  lungs  and  large  lymph 
glands,  194 

W 

Waldeyer,  ring  of,  201 

Walpurgisnacht,  25 

Warden,  larvngoscope  of,  206 

Wars  of  Italy,  128 

Wassermann  reaction  in  oztena,  305 

Water,  effects  of,  on  nasal  mucosa,  184 

Whooping  cough,  156 

confusion  with  influenza,  152 
Willis,  theory  of,  131 
Wind,  bile,  phlegm,  58 
Wire  of  harpsichord  for  snare,  162,  163 
Witch  medicine,  25 
Witches,  burning  of,  128 
Worms  in  frontal  sinus,  170 
Writing  introduced  in  Greece,  36 


Zend  Avesta,  26 


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